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Objectives: To evaluate outcomes of management without surgical revascularization in patients with acute lower limb ischemia (ALI) in a population-based setting. Design: Retrospective observational population-based study. Materials: Patients from Malmö, Sweden, hospitalized for ALI between 2015 and 2018. Methods: In-hospital, surgical, radiological, and autopsy registries were scrutinized for descriptive data on ALI patients managed by endovascular and open vascular surgery, conservative vascular therapy, primary major amputation, and palliative care. Results: Among 161 patients, 73 (45.3%) did not undergo any operative revascularization. Conservative vascular therapy, primary amputation, and palliative care were conducted in 25 (15.5%), 26 (16.1%), and 22 (13.7%) patients, respectively. Conservatively treated patients had Rutherford class ≥ IIb ischemia and embolic occlusion in 33% and 68% of cases, respectively. Their median C-reactive protein level at admission was 7 mg/L (interquartile range 2 – 31 mg/L). Among conservatively treated patients, anticoagulation therapy in half to full dose was given to 22 (88%) patients for six weeks or longer, and analgesics in low or moderate doses were given to twelve (48%) patients at discharge. The major amputation rate at 1 year was 8% among conservatively treated patients, and four patients with foot embolization had not undergone amputation at 1 year. Conclusion: Patients selected for initial conservative therapy of ALI with anticoagulation alone may have a good outcome, even when admitted with Rutherford class IIb ischemia. A low C-reactive protein level at admission seems to be a favorable marker when choosing conservative therapy. A prospective, preferably multicenter, study with a predefined protocol in these conservatively treated patients is warranted to better define the dose and length of anticoagulation therapy. [ABSTRACT FROM AUTHOR]

• Most suicide victims were dead at the scene, and most homicide victims died during hospital care. • In suicides, stab injuries involving the heart and/or injuries considered unsurvivable (NISS 75) were more often observed. • In homicides, injuries involving vessels were more often observed. • Only suicides died of the minor injuries (NISS ≤ 8) causing pneumothorax, intraabdominal bleeding or incarcerated abdominal wall hernia. Homicides using knives or other sharp objects are the most common type of homicide in Europe, and the second most common type of homicide worldwide. In contrast, suicides using sharp objects are rarer, constituting only a few per cent of all suicides in western countries. We investigated single stab injuries to the trunk in both homicides and suicides to assess differences in extent of injuries and in medical care, which could be of value for trauma management, public health and forensic assessment. We identified all cases in Sweden between 2010 and 2021 that died of a single stab to the trunk, in either a homicide (n = 94) or a suicide (n = 45), and that were the subject of a forensic autopsy. We obtained data on demographics, hospital care and injured structures. To assess the severity of injuries, we applied AIS (Abbreviated Injury Score) and NISS (New Injury Severity Score). The inter-rater reliability of NISS between two raters was evaluated with intra-class correlation (ICC), with 95 % confidence intervals (CI). The data was analysed using Fisher's exact test, Mann-Whitney U test and logistic regression models. The inter-rater reliability between the two NISS raters showed an ICC of 0.87 (95 % CI 0.68−0.95). We observed a larger variation of injuries in suicides, with a higher proportion of both unsurvivable (NISS 75) and minor injuries (NISS ≤ 8) (66.7 % and 8.9 % respectively) compared to in homicides (46.8 % and 0 % respectively). We observed a larger proportion of injuries to the heart in suicides (68.9% vs. 46.8 %, p = 0.018). In homicides, injuries involving vessels (52.1% vs. 13.3 %, p < 0.001) and hospital care (56.4 % vs. 8.9 %, p < 0.001) were significantly more common compared to suicides. Causation (self-inflicted or assaults) seems to be associated with characteristics of injury and the likelihood of receiving hospital care. These findings could potentially be valuable for trauma management and forensic assessment of manner of death, however, determining the mortality of the injuries would require a comparison group comprising injured survivors. [ABSTRACT FROM AUTHOR]

We evaluated if plasma biomarkers can predict incident peripheral arterial disease (PAD) and mortality in a longitudinal cohort study. Men (n = 3618) and women (n = 1542) were included in the Malmö Preventive Project and underwent analysis of: C-terminal endothelin-1 (CT-proET-1), N-Terminal prosomatostatin (NT-proSST), midregional proatrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and copeptin. Participants were followed up for incident PAD and mortality until December 31, 2016. Median follow-up was 11.2 years (interquartile range 9.4-12.2). Cumulative incidence of PAD was 4.3% (221/5160), 4.5% in men (164/3618) and 3.7% in women (57/1542; P =.174). In an adjusted Cox proportional hazards regression model, higher CT-proET-1 (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.4-2.3), NT-proSST (HR 1.5; 95% CI 1.2-2.0), and MR-proANP (HR 1.7; 95% CI 1.3-2.3) were independently associated with incident PAD, and higher CT-proET-1 (HR 1.3; 95% CI 1.2-1.5), NT-proSST (HR 1.2; 95% CI 1.1-1.3), MR-proANP (HR 1.4; 95% CI 1.3-1.6), PCT (HR 1.1; 95% CI 1.0-1.2), and copeptin (HR 1.2; 95% CI 1.1-1.4) were independently associated with mortality. Increased levels of CT-proET-1, NT-proSST, and MR-proANP were independently associated with incident PAD, whereas all the vasoactive biomarkers were independently associated with mortality during follow-up. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate fibre, and plant foods, and its association with AAA risk. Methods: In this prospective cohort study, Malmö Diet and Cancer Study, baseline data collection was carried out 1991–1996. The study participants' (n = 26,133) dietary habits were extensively recorded at baseline. The specific diagnosis of AAA in the in-hospital registry was found valid in 95%. The association between plant foods, such as cereals and types of vegetables, and AAA was assessed by using Cox regression analysis expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results: A high intake of fibre was independently associated with AAA risk (HR per quintile 0.87, 95% CI 0.79–0.97). High intake of vegetables (HR 0.91, 95% CI 0.84–0.98), specifically leaf vegetables (HR 0.87, 95% CI 0.81–0.94), and fruits and berries (HR 0.89, 95% CI 0.82–0.96), citrus (HR 0.91, 95% CI 0.85–0.98) and non-citrus fruits (HR 0.87, 95% CI 0.81–0.95) were independently associated with a decreased AAA risk. Conclusions: A high intake of fruits and berries and vegetables, in particular leaf vegetables, are associated with a decreased risk of developing AAA. [ABSTRACT FROM AUTHOR]

Prospective clinical plasma biomarker studies in abdominal aortic aneurysm (AAA) pathogenesis have been hampered by the need for very large cohorts and long follow-up time. The main aim of the present study was to evaluate the association of adrenomedullin, a cardiovascular (CV) stress marker, and incident AAA risk. Prospective longitudinal cohort of middle-aged individuals from the CV cohort of the Malmö Diet and Cancer Study (n = 5551; 1991-1994) was assessed. Plasma concentrations of midregional proadrenomedullin (MR-proADM), C-reactive protein (CRP), and conventional risk factors were measured at baseline. Incidence of AAA was studied up to December 31, 2013. Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%). Mean age of individuals with incident AAA was 59.7 years at study entry, and AAA was diagnosed on average 14 years later. Adjusting for age, gender, smoking, body mass index, hypertension, diabetes mellitus, and CRP, MR-proADM (hazard ratio: 1.28; 95% confidence interval: 1.01-1.62) was independently associated with incident AAA. The plasma biomarker MR-proADM seems to be a marker of AAA risk, implying that AAA development may be driven by long-standing CV stress on the aortic wall. [ABSTRACT FROM AUTHOR]

Aims and objectives To explore experiences of negative pressure wound therapy at home, in patients with deep perivascular groin infection after vascular surgery and management in daily life. Background Deep surgical site infection after vascular surgery with exposed vessels often requires long-term treatment with negative pressure wound therapy, and continued therapy at home has become routine. Design An explorative qualitative study. Methods Nine men and six women with a deep surgical site infection in the groin after vascular surgery, treated in their home with negative pressure wound therapy, were interviewed. The interviews were analysed using manifest and latent content analysis. Results Undergoing negative pressure wound therapy at home meant a transition from being a dependent patient to a person who must have self-care competence and be involved in their own care. A need to feel prepared for this before discharge from hospital was expressed. Lack of information and feelings of uncertainty prolonged the time before feeling confident in managing the treatment. The informants gradually accepted the need to be tied up to a machine, became competent in its management and found solutions to perform everyday tasks. Overall, it was a relief to be treated at home. Conclusions Several benefits of negative pressure wound therapy at home were expressed. However, unnecessary stress and anxiety were experienced due to a lack of information on the treatment and instruction concerning the equipment. Adequate information and education must therefore be provided to facilitate the transition from a patient to a person with self-care competence and ability to manage this treatment at home. Relevance to clinical practice The findings revealed a need for more support and knowledge in their transition from hospital care to home care with negative pressure wound therapy. Routines must be established that ensure patient safety and security in treatment at home. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate whether screening for abdominal aortic aneurysm (AAA) has led to a decrease in ruptured AAA (rAAA) incidence.Method: The Malmö population was evaluated regarding the incidence of rAAA and elective AAA surgery 4 years before and after start of AAA-screening in 2010. Data from 1971 to 1986 (J Vasc Surg 18:74-80, 1993) and 2000-2004 (J Vasc Surg 44:237-43, 2006), enabled analysis of trends over time.Results: Analysis of time-periods 1971-1986, 2000-2004, 2006-2010 and 2010-2014 showed an incidence of rAAA of 5.6 (4.9-6.3), 10.6 (8.9-12.4), 6.1 (4.6-7.6) and 4.0 (2.9-5.1), respectively. In men aged 60-69 years the incidences were 16.0 (10.7-21.3), 45.6 (27.7-63.4), 19.3 (9.2-35.3) and 8.9 (2.8-20.6), respectively. The incidences of elective AAA surgery in men aged 60-69 years were 22.9 (16.5-29.2), 34.6 (19.1-50.2), 9.7 (1.2-18.5) and 44.2 (27.0-61.6), respectively.Conclusions: A decrease in incidence of rAAA in men was evident before the implementation of screening. We were yet not able to demonstrate a certain reduction in rAAA incidence after the start of screening. [ABSTRACT FROM AUTHOR]

Aims: We applied the new injury severity scoring system and studied mechanisms of injury and risk factors for mortality, in order to find potential preventive measures, in the present Scandinavian trauma cohort triaged through red trauma alarm according to the Medical Emergency Triage and Treatment System. Methods: Individuals were identified in hospital and forensic records. New injury severity scoring system >15 was defined as major trauma. Inter-rater reliability of new injury severity scoring system was expressed as intra-class correlation coefficient with 95% confidence intervals. Results: There were 125 major and 303 minor traumas. The intra-class correlation coefficient was 0.83 (95% confidence intervals 0.58–0.94) for major trauma and intra-class correlation coefficient was 0.96 (95% confidence intervals 0.89–0.98) for minor trauma. Traffic (37%) and fall (31%) accidents were the leading mechanisms of injury. Elderly (aged ⩾65 years) were at an increased risk of fall accidents (p<0.001). The overall 3 month mortality rate was 10.3% (2% for new injury severity scoring system 16–24, 39% for new injury severity scoring system 25–40 and 68% for new injury severity scoring system >40). A higher new injury severity scoring system score (p<0.001), higher age (p<0.001), shock at admission (p<0.001), intensive care unit stay (p<0.004) and administration of massive red blood cell transfusion (p<0.048) were associated with mortality. Thirty-three patients underwent forensic autopsy and were tested positive for one or multiple drugs in 52% and 33%, respectively. Conclusions: The high prevalence of detected drugs among those undergoing forensic toxicological examination suggests that toxicology screening should be integrated into all red trauma alarm admissions, which may have implications on prevention of future trauma morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the incidence, complications, and outcome of local intra-arterial thrombolytic therapy for acute superior mesenteric artery (SMA) occlusion in Sweden. Methods: Patients undergoing local intra-arterial thrombolytic therapy for acute SMA occlusion were identified in the Swedish Vascular Registry (SWEDVASC) between 1987 and 2009. Patient data were retrieved in a structured protocol by local vascular surgeons at each participating hospital. Results: Included were 34 patients (20 women) from 12 hospitals. Median age was 78 years. The first patient was treated in 1997, and the annual number of patients undergoing thrombolysis increased continuously from 2004 to 2009. Twenty-eight patients (82%) had embolic occlusion. No patients (0%) had acute peritonitis, and one (3%) had bloody stools at admission. Thirty-two patients (94%) were diagnosed by computed tomography with intravenous contrast enhancement. The median dose of alteplase was 20 mg (interquartile range, 11.6-34.0). Successful thrombolysis was achieved in 30 patients (88%). Initial adjunctive aspiration thromboembolectomy was performed in 10 patients. There were six self-limiting bleeding complications; one from the gastrointestinal tract. Thirteen explorative laparotomies, 10 repeat laparotomies, and eight bowel resections were performed. The in-hospital mortality rate was 26% (9 of 34). Age was not associated with in-hospital death (P = .42). Successful thrombolysis was associated with decreased mortality (P = .048). Conclusion: Local thrombolysis for acute SMA occlusion is a minimally invasive and effective treatment alternative in a select group of patients without peritonitis. The few technique-related complications were mild. [Copyright &y& Elsevier]

Background: Reports on trends in incidence and mortality of acute superior mesenteric artery (SMA) occlusion and evaluation of prognostic factors in recent years are lacking.Methods: Patients with acute SMA occlusion were identified through the in-patient and autopsy registry between 1970 and 1982 (n = 270), 1987 to 1996 (n = 135), and 2000 and 2006 (n = 100) in Malmö, Sweden.Results: The overall incidence rate decreased from 8.6 to 5.4/100,000 person years and the autopsy rate from 87% to 25% over time. A higher serum creatinine level was associated with a lower probability of undergoing multi-detector row computed tomography with intravenous contrast (MDCTiv) (p = 0.006). Not performing a MDCTiv (odds ratio 4.0; 95% confidence interval [1.0-16.0]) remained as independent prognostic factor for in-hospital mortality. General and vascular surgeons collaborated in 25 out of 61 patients that underwent an intervention, of which 21 (84%) (p < 0.001) survived.Conclusions: A close collaboration between radiologists and general and vascular surgeons seems to be most important to lower the mortality in patients with acute SMA occlusion. [ABSTRACT FROM AUTHOR]

The overall incidence rate of acute mesenteric ischemia between 1970 and 1982, diagnosed at either autopsy or operation, in the population of Malmö, Sweden was estimated at 12.9/100,000 person-years. Autopsy rate was 87%. Acute superior mesenteric artery (SMA) occlusion (embolus/thrombus ratio = 1.4), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI) were found in approximately 68%, 16%, and 16%, respectively. Acute SMA occlusion was found to be more common than ruptured abdominal aortic aneurysms. The incidence increased exponentially with age, equally distributed among men and women after adjusting for age and gender in the population. Thrombotic occlusions were located more proximally than embolic occlusions and intestinal infarction was more extensive, whereas patients with embolus had a higher frequency of acute myocardial infarction, and had cardiac thrombi in 48% and synchronous emboli in 68% of the patients. The proportion of patients with symptoms inherent with chronic mesenteric ischemia prior to onset of acute thrombotic occlusion has been reported to occur in 73%. Cardiac failure, history of atrial fibrillation, and recent surgery have all been associated with fatal NOMI. MVT is either caused by thrombophilia, direct injury, or local venous congestion or stasis. Multidetector row computed tomography with intravenous contrast enhancement and imaging in the arterial phase for suspicion of acute SMA occlusion and imaging in the venous phase for MVT has become the diagnostic method of choice. In-hospital mortality is highest for NOMI, lower for acute SMA occlusion, and lowest, around 20%, for MVT. [Copyright &y& Elsevier]

Objectives. To estimate the incidence of fatal colonic ischaemia (CI) and the cause-specific mortality of CI, and to describe the localization and extension of colonic infarction and quantify the risk factors associated with CI.Material and methods. Between 1970 and 1982 the autopsy rate in Malmö, Sweden, was 87%, creating the possibilities for a population-based study. Out of 23,446 clinical autopsies, 997 cases were coded for intestinal ischaemia in a database. In addition, 7569 forensic autopsy protocols were analysed. In a case-control study nested in the clinical autopsy cohort, four CI-free controls, matched for gender, age at death and year of death, were identified for each fatal CI case in order to evaluate the risk factors.Results. The cause-specific mortality ratio was 1.7/1000 autopsies. The overall incidence of autopsy-verified fatal CI was 1.7/100,000 person years, increasing with age up to 23/100,000 person years in octogenarians. Fatal cardiac failure (odds ratio (OR) 5.2), fatal valvular disease (OR 4.3), previous stroke (OR 2.5) and recent surgery (OR 3.4) were risk factors for fatal CI. Narrowing/occlusion of the inferior mesenteric artery (IMA) at the aortic origin was present in 68% of the patients. The most common segments affected by transmural infarctions were the sigmoid (83%) and the descending (77%) colon.Conclusions. Heart failure, atherosclerotic occlusion/stenoses of the IMA and recent surgery were the main risk factors causing colonic hypoperfusion and infarction. Segments of transmural infarctions were observed within the left colon in 94% of the patients. Awareness of the diagnosis and its associated cardiac comorbidities might help to improve survival. [ABSTRACT FROM AUTHOR]

Background/objectives: Acute mesenteric ischemia (AMI) is life-threatening and difficult to diagnose in time. Unlike many cardiovascular diseases, the association between lifestyle factors such as diet, alcohol consumption, and physical activity and AMI is unknown., Methods: This study is a prospective cohort study with 28,098 middle-aged participants with a mean follow-up time of 23.1 years. Baseline characteristics were obtained with questionnaires regarding physical activity, lifestyle, and diet. The primary endpoint was a diagnosis of AMI identified through the Swedish National Patient Register. Follow-up times were decided by the date of diagnosis, death, or end of follow-up, 2022-12-31., Results: The total number of patients with AMI was 140. Current smoking (adjusted hazard ratio [aHR] 3.02, 95% confidence interval [CI] 1.91-4.79) and those with the highest alcohol consumption (aHR 2.53, 95% CI 1.27-5.03) had a higher risk of developing AMI. Participants with high physical activity, 25.1-50.0 metabolic equivalent task hours per week (MET-h/week), had a lower risk (aHR 0.51, 95% CI 0.27-0.95). Diet quality and dietary components did not affect the risk of AMI., Conclusions: Smoking and higher alcohol consumption were associated with higher risk, while physical activity was associated with lower risk of AMI in this prospective cohort. Diet quality and dietary components were less relevant for the prediction of AMI than these traditional risk factors of atherosclerotic disease.

Introduction: The potential utility of inflammatory and hemodynamic plasma biomarkers for the prediction of incident lower extremity arterial disease (LEAD), carotid artery stenosis (CAS), isolated atherosclerotic disease without concomitant abdominal aortic aneurysm (AAA), and isolated AAA without concomitant atherosclerotic disease has not yet been integrated in clinical practice. The main objective of this prospective study was to find predictive plasma biomarkers for cardiovascular disease and to evaluate differences in plasma biomarker profiles between asymptomatic and symptomatic CAS, as well as between isolated atherosclerotic disease and isolated AAA., Methods: Blood samples collected at baseline from participants in the prospective Malmö Diet and Cancer study (MDCS) cardiovascular cohort (n = 5550 middle-aged individuals; baseline 1991-1994) were used for plasma biomarker analysis. Validation of each incident cardiovascular diagnosis was performed by random sampling. Cox regression analysis was used to calculate hazard ratios (HRs) per one standard deviation increment of each respective log-transformed plasma biomarker with 95% confidence intervals (CI)., Results: Adjusted lipoprotein-associated phospholipase A2 (Lp-PLA 2 ) activity (HR 1.33; CI 1.17-1.52) and mass (HR 1.20; CI 1.05-1.37), C-reactive protein (CRP) (HR 1.55; CI 1.36-1.76), copeptin (HR 1.46; CI 1.19-1.80), N-terminal pro-B-type natriuretic peptide (N-BNP) (HR 1.28; 1.11-1.48), and cystatin C (HR 1.19; 95% 1.10-1.29) were associated with incident symptomatic LEAD. Adjusted N-BNP (HR 1.59; CI 1.20-2.11), mid-regional proadrenomedullin (HR 1.40; CI 1.13-1.73), cystatin C (HR 1.21; CI 1.02-1.43), and CRP (HR 1.53; CI 1.13-1.73) were associated with incident symptomatic but not asymptomatic CAS. Adjusted HR was higher for Lp-PLA 2 (mass) for incident isolated AAA compared to for isolated atherosclerotic disease., Conclusions: Plasma biomarker profile data support that subclinical vascular inflammation and cardiovascular stress seem to be relevant for the development of atherosclerotic disease and AAA.

Aims: The aim of this study is to investigate how genetic variations in genes related to oxidative stress, intake of antioxidant vitamins, and any potential interactions between these factors affect the incidence of intact abdominal aortic aneurysm (AAA) and its rupture (rAAA), accounting for sex differences where possible., Methods and Results: The present retrospective cohort study (n = 25 252) uses baseline single-nucleotide polymorphisms (SNPs) and total antioxidant vitamin intake data from the large population-based, Malmö Diet and Cancer Study. Cumulative incidence of intact AAA was 1.6% and of rAAA 0.3% after a median follow-up of 24.3 years. A variant in NOX3 (rs3749930) was associated with higher rAAA risk in males [adjusted hazard ratio (aHR): 2.49; 95% confidence interval (CI): 1.36-4.35] and the overall population (aHR: 1.88; 95% CI: 1.05-3.37). Higher intakes of antioxidant vitamins, riboflavin, and folate were associated with 20% and 19% reduced intact AAA incidence, respectively. Interestingly, the inverse associations between riboflavin and vitamin D intake with intact AAA incidence were stronger in the individuals carrying the NOX3 variant as compared with the wild-type recessive genotype, i.e. by 60% and 66%, respectively (P for interaction < 0.05). Higher riboflavin intake was associated with a 33% male-specific intact AAA risk reduction, while higher intake of vitamin B12 intake was associated with 55% female-specific intact AAA risk increase; both these associations were significantly modified by sex (P for interaction < 0.05)., Conclusions: Our findings highlight the role of oxidative stress genetic variations and antioxidant vitamin intake in AAA. Although a low AAA/rAAA sample size limited some analyses, especially in females, our findings highlight the need for future randomized controlled trials and mechanistic studies, to explore the potential benefits of antioxidant vitamins while accounting for genetic and sex differences., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: Forensic pathologists are frequently confronted with questions about whether an injury is likely to have been inflicted by an assault or be self-inflicted. However, little is known of the epidemiological variables that might be applicable to differentiate between homicides and suicides in deaths caused by single stab injuries to the trunk., Method: Using the Swedish forensic autopsy register, we identified 94 homicides and 45 suicides between 2010 and 2021 in which death followed a single stab injury to the trunk. We extracted characteristics from the cases and performed statistical analyses using the Mann-Whitney U test, Chi-square test and logistic regression model., Results: Victims of homicides were younger than suicide victims (median age 33 years vs. 52 years, p < 0.05), and males were in the majority in both groups (93% vs. 82%). In numerous homicide victims, stab wounds were placed in the back and in axillar regions, unlike in suicides victims in which the stabs were all placed on the medial part of the anterior trunk. Vertical entrance wounds in the skin combined with a medially running injury channel (n = 13) showed a positive predictive value of 100% (95% CI 75.3-100) for homicide, although the sensitivity was low. Homicides were conclusively associated with an outdoor death scene (OR 19.0, 95% CI 7.6-47.1), injury to thoracic bone/cartilage (OR 3.8, 95% CI 1.6-9.0), influence of alcohol (OR 7.1, 95% Cl 2.9-17.7) and illicit drugs (OR 4.3, 95% CI 1.5-11.9)., Discussion and Conclusion: The observed forensic characteristics of stab injuries could be used as a tool when assessing the manner of death in single stabs. Further research on variables associated with manner of death are needed and we suggest also including characteristics of surviving victims in such analyses., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to evaluate the contemporary population based incidence of acute lower limb ischaemia (ALI) and factors associated with major amputation/death at one year., Methods: In this retrospective observational study, in hospital, operation, radiological, and autopsy registries were scrutinised to capture 161 citizens of Malmö, Sweden, with ALI between 2015 and 2018. Age and sex specific incidence rates were calculated in the population of Malmö between 2015 and 2018, expressed as number of patients per 100 000 person years (PY). Independent risk factors for major amputation/death at one year were identified by multivariable logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs)., Results: One hundred and sixty-one patients with ALI gave an overall incidence of 12.2/100 000 PY (95% CI 10.3 - 14.1), with no sex related differences. Embolism (42.2%) was the most common cause of ALI. Among 52 patients with atrial fibrillation, 38.5% were on anticoagulant medication. Endovascular or open vascular revascularisation was performed in 54.7% of patients. The total cause specific mortality ratio was 2.63 (95% CI 1.66 - 3.61)/1 000 deaths, without no sex related differences. The combined major amputation/mortality rate at one year for the whole cohort was 46.6%. Rutherford ≥ IIb ALI (OR 4.19, 95% CI 1.94 - 9.02; p < .001), age (OR 1.03/year, 95% CI 1.00 - 1.06; p = .036), female sex (OR 2.37, 95% 1.07 - 5.26; p = .034), and anaemia (OR 2.46, 95% CI 1.08 - 5.62; p = .033) were associated with an increased risk of major amputation/death at one year. The major amputation/mortality rate at one year was 100% (n = 14/14) for patients living in a nursing home on admission., Conclusion: The incidence of ALI appears to be unchanged, and major amputation and mortality at one year remain high. It is necessary to include the substantial proportion of patients with ALI that do not undergo revascularisation in epidemiological studies. There is room for improvement in anticoagulation therapy in patients with atrial fibrillation to prevent ALI due to embolism. Research on gender inequalities in patients with ALI is warranted., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Risk factors for ischemic stroke is suggested to differ by etiologic subtypes. The purpose of this study was to examine the associations between modifiable and non-modifiable risk factors and atherothrombotic stroke (i.e., excluding cardioembolic stroke), and to examine if the potential benefit of modifiable lifestyle factors differs among subjects with and without predisposing comorbidities. After a median follow-up of 21.2 years, 2339 individuals were diagnosed with atherothrombotic stroke out of 26,547 study participants from the Malmö Diet and Cancer study. Using multivariable Cox regression, we examined non-modifiable (demographics and family history of stroke), semi-modifiable comorbidities (hypertension, dyslipidemia, diabetes mellitus and atherosclerotic disease), and modifiable (smoking, body mass index, diet quality, physical activity, and alcohol intake) risk factors in relation to atherothrombotic stroke. Higher age, male gender, family history of stroke, and low educational level increased the risk of atherothrombotic stroke as did predisposing comorbidities. Non-smoking (hazard ratio (HR) = 0.62, 95% confidence interval (CI) 0.56-0.68), high diet quality (HR = 0.83, 95% CI 0.72-0.97) and high leisure-time physical activity (HR = 0.89, 95% CI 0.80-0.98) decreased the risk of atherothrombotic ischemic stroke independent of established risk factors, with non-significant associations with body mass index and alcohol intake. The effect of the lifestyle factors was independent of predisposing comorbidities at baseline. The adverse effects of several cardiovascular risk factors were confirmed in this study of atherothrombotic stroke. Smoking cessation, improving diet quality and increasing physical activity level is likely to lower risk of atherothrombotic stroke in the general population as well as in patient groups at high risk.

Objective: To identify factors affecting the outcome after open surgical (OSR) and endovascular (ER) repair of popliteal artery aneurysm (PA) in comparable cohorts., Methods: A matched comparison in a national, population based cohort of 592 legs treated for PA (2008 - 2012), with long term follow up. Registry data from 899 PA patients treated in 2014 - 2018 were analysed for time trends. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records and imaging were collected. Analysed risk factors were anatomy, comorbidities, and medication. Elongation and angulations were examined in a core lab. The main outcome was occlusion., Results: Patients in the ER group were older (73 vs. 68 years, p = .001), had more lung disease (p = .012), and were treated with dual antiplatelet therapy or anticoagulants more often (p < .001). The hazard ratio (HR with 95% confidence intervals) for occlusion was 2.69 (1.60 - 4.55, p < .001) for ER, but 3.03 (1.26 - 7.27, p = .013) for poor outflow. For permanent occlusion, the HR after ER was 2.47 (1.35 - 4.50, p = .003), but 4.68 (1.89 - 11.62, p < .001) for poor outflow. In the ER subgroup, occlusion was more common after acute ischaemia (HR 2.94 [1.45 - 5.97], p = .003; and poor outflow HR 14.39 [3.46 - 59.92], p < .001). Larger stent graft diameter reduced the risk (HR 0.71 [0.54 - 0.93], p = .014). In Cox regression analysis adjusted for indication and stent graft diameter, elongation increased the risk (HR 1.020 per degree [1.002 - 1.033], p = .030). PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, with those for elective procedures being 8 mm (p < .001). Indications and outcomes were similar during both time periods (2008 - 2012 and 2014 - 2018)., Conclusion: In comparable groups, ER had a 2.7 fold increased risk of any occlusion, and 2.4 fold increased risk of permanent occlusion, despite more aggressive medical therapy. Risk factors associated with occlusion in ER were poor outflow, smaller stent graft diameter, acute ischaemia, and angulation/elongation. An association between indication, acute ischaemia, and small stent graft diameter was identified., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Aim: To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM)., Methods: In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively., Results: The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14)., Conclusions: Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes., Competing Interests: Declaration of competing interest The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Plasma biomarkers may be useful to detect healthy individuals at increased risk for atherosclerotic manifestations, such as carotid artery stenosis. The aim of this longitudinal cohort study was to evaluate new biomarkers in relation to C-reactive protein and conventional risk factors for carotid artery stenosis during long term follow-up METHODS: The following markers were measured in 5550 middle-aged subjects: C-reactive protein, lipoprotein-associated phospholipase A2, proneurotensin, midregional pro-adrenomedullin, midregional pro-atrial natriuretic peptide, N-terminal pro B-type natriuretic peptide, copeptin, and cystatin C. Subjects with prevalent carotid artery stenosis were excluded. Subjects were followed in national patient registers for 23.4 (interquartile range 19.5-24.3) years regarding incident carotid artery stenosis, both operated and non-operated., Results: When including conventional risk markers in Cox regression, N-terminal pro B-type natriuretic peptide (Hazard ratio 1.36; 95% confidence interval 1.12-1.65; p = 0.002) was independently associated with incident carotid artery stenosis, whereas there were trends for C-reactive protein (HR 1.20; 95% confidence interval 0.98-1.48; p = 0.071), and midregional pro-adrenomedullin (Hazard ratio 1.21; 95% confidence interval 0.99-1.47; p = 0.061). Midregional pro-adrenomedullin (Hazard ratio 1.30; 95% confidence interval 1.03-1.65; p = 0.029) was independently associated with incident surgery for carotid artery stenosis, whereas there was a trend for N-terminal pro B-type natriuretic peptide (Hazard ratio 1.31; 95% confidence interval 1.00-1.72; p = 0.052)., Conclusions: N-terminal pro B-type natriuretic peptide and midregional pro-adrenomedullin can be used as predictors for clinically detected carotid artery stenosis during long-term follow-up of healthy subjects., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Even though abdominal aortic aneurysm (AAA) and coronary heart disease (CHD) are both related to atherosclerosis, there could be important differences in risk factors. Based on Malmö Diet and Cancer Cohort, the incidence of AAA and CHD was followed prospectively. Cox regression was used to calculate the association of each factor with AAA and CHD and hazards ratio were compared using a modified Lunn-McNeil method; 447 participants developed AAA and 3129 developed CHD. After multivariate adjustments, smoking, antihypertensive medications, lipid-lowing medications, systolic and diastolic blood pressures, apolipoprotein (Apo) A1 (inversely), ApoB, ApoB/ApoA1 ratio, total leukocyte count, neutrophil count, and neutrophil to lymphocyte ratio were associated with the risks of both AAA and CHD. When comparing risk factor profiles for the 2 diseases, smoking, diastolic blood pressure, ApoA1, and ApoB/ApoA1 ratio had stronger associations with risk of AAA than with risk of CHD, while diabetes and unmarried status showed increased risk of CHD, but not of AAA (all P values for equal association <.01). The results from this big population study confirm that the risk factor profiles for AAA and CHD show not only many similarities but also several important differences.

Red cell distribution width (RDW) has been suggested to have a predictive potential for several cardiovascular diseases, but its association with abdominal aortic aneurysm (AAA) is unknown. We examined whether RDW is associated with the risk of AAA among 27,260 individuals from the population-based Malmö Diet and Cancer Study cohort. Data of baseline characteristics were collected during 1991-1996. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for AAA across quartiles of RDW. During a median follow-up of 21.7 years, 491 subjects developed AAA. After adjustment for other confounding factors, participants in the highest quartile of RDW experienced 61% increased risk of AAA as compared to those with the lowest quartile (HR = 1.61, CI = 1.20, 2.12). RDW showed similar relationship with severe (i.e. ruptured or surgically repaired) AAA or non-severe AAA (adjusted HR 1.58 and 1.60, respectively). The observed association between RDW and AAA risk was significant in current smokers (adjusted HR = 1.68, CI = 1.18, 2.38) but not in former smokers (adjusted HR = 1.13, CI = 0.72, 1.79), or never-smokers (adjusted HR = 1.77, CI = 0.74, 4.22). Elevated RDW is associated with increased future incidence of AAA, however the causal and pathophysiological mechanisms remain to be explored.

Objective: Epidemiologic data indicate decreased risk for development, growth, and rupture of abdominal aortic aneurysm (AAA) among patients with type 2 diabetes mellitus (DM). We therefore evaluated mortality and cardiovascular morbidity after acute repair of AAA in diabetic and nondiabetic patients., Methods: In this nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Register, we compared mortality and morbidity after acute open (n = 1357 [61%]) or endovascular (n = 860 [39%]) repair of ruptured (n = 1469 [66%]) or otherwise symptomatic (n = 748 [34%]) AAAs in 363 patients with and 1854 patients without DM with propensity score-adjusted analysis., Results: Follow-up was 3.91 years for patients with DM and 3.18 years for those without. In propensity-adjusted analysis, diabetic patients showed lower total mortality (relative risk [RR], 0.75; 95% confidence interval [CI], 0.59-0.95; P = .016) and cardiovascular mortality (RR, 0.17; 95% CI, 0.06-0.50; P = .01) than those without DM, whereas there were no differences in rates of major adverse cardiovascular events (RR, 1.10; 95% CI, 0.87-1.42; P = .42), acute myocardial infarction (RR, 1.36; 95% CI, 0.70-2.63; P = .37), or stroke (RR, 1.31; 95% CI, 0.84-2.03; P = .23)., Conclusions: Patients with type 2 DM had lower rates of both total and cardiovascular mortality after acute AAA repair than those without DM, whereas rates of cardiovascular events, acute myocardial infarction, and stroke did not differ between groups. This might be explained by putative protective effects of DM on the aortic wall., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Stroke is one of the leading causes of death, and out of all stroke cases, 10-15% originate from a previously asymptomatic stenosis in the internal carotid artery., Aims: The aim of the study was to investigate whether dietary and lifestyle habits were associated with future risk of incident carotid artery disease (CAD)., Methods: Baseline examinations on middle-aged individuals (n = 30,447) in the Malmö Diet and Cancer study (MDCS), a prospective cohort study, took place between 1991 and 1996 in Malmö, Sweden. Individuals with cardiovascular disease and diabetes mellitus were excluded at baseline, resulting in a total study population of 25,952 patients. Information on dietary intake was gathered through a 7-day food diary, a detailed questionnaire, and a 1-h interview. A diet quality index was calculated from adherence to recommended intake of 6 dietary components (saturated fat, polyunsaturated fat, fish and shellfish, fiber, vegetables and fruit, and sucrose). Individuals with a first registered diagnosis of CAD were identified from the Swedish National Patient register., Results: During a median follow-up of 21.8 years, 469 participants (1.8%) developed CAD. The diagnosis of incident CAD was validated and confirmed in 99% of a random sample of 100 individuals. Higher intake of vegetables and fruit was associated with a trend of decreased risk of CAD in a Cox regression analysis (hazard ratio of 0.76, 95% confidence interval 0.56-1.03; p = 0.080)., Conclusions: In conclusion, the present study found a trend toward a protective effect of higher intake of vegetables and fruit against incident CAD. More prospective studies investigating the association between diet and CAD and stroke are needed in order to give firm recommendations., (© 2020 The Author(s) Published by S. Karger AG, Basel.)

Epidemiological data indicate decreased risk for development and growth of abdominal aortic aneurysm (AAA) among patients with diabetes mellitus (DM). On the other hand, DM adds to increased cardiovascular (CV) morbidity and mortality. In a nationwide observational cohort study of patients registered in the Swedish Vascular Register and the Swedish National Diabetes Register, we evaluated potential effects of DM on total mortality, CV morbidity, and the need for reintervention after elective endovascular aneurysm repair (EVAR) for AAA. We compared 748 patients with and 2630 without DM with propensity score-adjusted analysis, during a median 4.22 years of follow-up for patients with DM, and 4.05 years for those without. In adjusted analysis, diabetic patients showed higher rates of acute myocardial infarction (AMI) during follow-up (relative risk (RR) 1.44, 95% CI 1.06-1.95; p = 0.02), but lower need for reintervention (RR 0.12, CI 0.02-0.91; p = 0.04). There were no differences in total (RR 0.88, CI 0.74-1.05; p = 0.15) or CV (RR 1.58, CI 0.87-2.86; p = 0.13) mortality, or stroke (RR 0.95, CI 0.68-1.32; p = 0.75) during follow-up. In conclusion, patients with DM had higher rates of AMI and lower need for reintervention after elective EVAR than those without DM, whereas neither total nor CV mortality differed between groups. The putative protective effects of DM towards further AAA enlargement and late sac rupture may help explain the lower need for reintervention and absence of excess mortality.

Peripheral artery disease (PAD) is caused by atherosclerosis and associated with an increased risk of leg amputation, cardiovascular disease, and death. A healthy diet has been shown to reduce the risk of cardiovascular events, but relationships between diet, fiber intake, and incidence of PAD are virtually unknown. The aim was to investigate the long-term impact of diet on the development of PAD among 26,010 middle-aged individuals in the prospective Malmö Diet and Cancer study (MDCS). Data on dietary intake were collected through a 7-day food diary combined with a food questionnaire and a 1-hour interview. Adherence to a recommended intake of six dietary components - saturated fat, polyunsaturated fat, fish and shellfish, fiber, fruit and vegetables, and sucrose - was scored (sum 0-6 points) to assess a diet quality index, adjusting for potential confounders. Cox regression analysis was used to estimate associations between diet variables and PAD incidence expressed in hazard ratios (HR) with 95% CI. During a median follow-up of 21.7 years, 1122 participants developed PAD. Diet score was associated with a reduced risk of PAD in multivariable analysis ( p = 0.03). When mutually adjusting for all dietary variables, only adherence to recommended levels of fiber intake was associated with a reduced risk of incident PAD (HR 0.84; 95% CI 0.72-0.99). In this prospective, population-based study including 26,010 participants with over 20 years of follow-up, a healthy diet, especially a high intake of fiber, was associated with a reduced risk of PAD. Primary prevention programs directed against PAD should therefore include a fiber recommendation.

Background. Aortic dissection (AD) and abdominal aortic aneurysm (AAA) share the same risk factors. Whereas the incidence of AAA is falling, it is unclear whether population-based incidences of acute type A and B AD have changed. The aim of this study was to investigate incidences of AD subtypes over time. Methods . Citizens in the municipality of Malmö, Sweden, diagnosed with AD in 2000-2004 and 2014-2016 were identified through the in-patient, clinical, and forensic autopsy registers. Results . The overall and gender-specific incidences of acute type A and B AD were stable over time. The overall autopsy rate declined from 25.2% in 2000-2004 to 16.1% in 2014-2016 ( p  = .0001) and patients with acute type A AD were more often encountered at autopsy (78% of cases) during the first time period, compared to 43% of cases during the second time period ( p  = .005), when the ratio of acute type A: acute type B AD was 2.6: 1. The proportion of individuals <65 years of age tended to be higher in acute type A AD compared to acute type B AD ( p  = .07). The frequencies of hypertension and smoking were 90% and 91%, respectively, in type A AD, and 86% and 86%, respectively in type B AD. Conclusions . Population-based incidences of acute type A and type B AD were stable over time, but the decreasing autopsy rate has led to a lower proportion of AD diagnosed at autopsy. Primary prevention towards hypertension and smoking seem necessary to reduce AD incidence.

Purpose: The aim of this study is to evaluate plasma biomarkers as predictors for peripheral arterial disease (PAD). Materials and methods: Prospective longitudinal cohort study of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer study (MDCS) ( n  = 5550; 1991-94). Cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional proatrial natriuretic peptide (MR-proANP), mid-regional proadrenomedullin (MR-proADM), and conventional risk factors were measured at baseline. The diagnosis of symptomatic PAD was validated in 97% of the cases. Results: Cumulative incidence of PAD during median follow up of 23.4 years was 4.4% (men 5.9%, women 3.3%). Adjusted for age, sex, smoking, body mass index, hypertension, diabetes mellitus and total cholesterol, copeptin (hazard ratio [HR] 1.46; 95% confidence interval [CI] 1.19-1.80), N-BNP (HR 1.28; 95% CI 1.11-1.48), and cystatin C (HR 1.19; 95% CI 1.10-1.29) were independently associated with incident PAD. Subjects with the three biomarkers copeptin, N-BNP, and cystatin C in the highest quartiles, ran a high risk of incident PAD (HR 3.29; 95% CI 1.76-6.17) compared to those with no biomarker in the highest quartile. Conclusion: Copeptin, N-BNP, and cystatin C were associated with incident symptomatic PAD, implying that these biomarkers are sensitive indicators of early subclinical PAD. Clinical significance First prospective longitudinal cohort study evaluating Cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional proatrial natriuretic peptide (MR-proANP), and mid-regional proadrenomedullin (MR-proADM) as predictors for peripheral arterial disease (PAD). Copeptin, N-BNP, and Cystatin C where independently associated with incident symptomatic PAD after adjustment for conventional risk factors. Copeptin, N-BNP, and Cystatin C seem to be sensitive indicators of early subclinical PAD.

Background: Epidemiological data indicate decreased risk for development and growth of abdominal aortic aneurysm (AAA) among patients with diabetes mellitus (DM), but DM also goes with increased cardiovascular (CV) morbidity and mortality. We evaluated the effects of DM on mortality and CV morbidity after elective open AAA repair., Methods: This is a nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Register. Comparison of mortality and CV morbidity after elective open AAA repair in 397 patients with and 1709 without DM with propensity score-adjusted analysis, during median 4.51 years of follow-up for patients with DM and 4.59 years for those without., Results: In adjusted analysis, diabetic patients showed higher rates of acute myocardial infarction (AMI) (relative risk [RR] 1.57, 95% confidence interval [CI] 1.04-2.36; P = 0.03) and major adverse cardiovascular events (MACEs, RR 1.28, CI 1.04-1.58; P = 0.02) during follow-up, whereas there were no differences in total (RR 0.98, CI 0.75-1.29; P = 0.91) or CV (RR 0.30, CI 0.07-1.26; P = 0.10) mortality or stroke (RR 1.06, CI 0.67-1.67; P = 0.80). Among diabetic patients, higher HbA1c was related to a higher risk for AMI during follow-up (RR 1.04, CI 1.01-1.08; P = 0.02)., Conclusions: Patients with DM had higher rates of AMI and MACE after elective open AAA repair than those without DM, whereas neither total nor CV mortality differed between groups. Putative beneficial effects of DM on the aortic wall might not be relevant after open surgery including thrombus removal and aneurysmorrhaphy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Due to the consistently high proportion of surgical site infections (SSI) after vascular surgery, a change of prophylactic antibiotic therapy from cloxacillin/cefotaxime to trimethoprim/sulfamethoxazole (TMP-SMX) was conducted in 2016. The study included consecutive patients undergoing lower extremity revascularization due to acute or chronic lower extremity arterial disease. The antibiotic regime was changed in between the two sampling periods (2014 -2016 versus 2016 -2017). The diagnosis of SSI was based on clinical examination and microbiological results, and severity was classified according to the Szilagyi classification. One hundred and twenty-two patients in the cloxacillin/cefotaxime and 67 patients in the TMP-SMX group were included. The SSI rates were 32.0% and 40.3%, respectively (p=0.25). The proportion of women were higher in the TMP-SMX group (32.8% versus 47.8%, respectively, p=0.043). No other differences between the two groups were found regarding patient, vascular surgery procedure characteristics or severity of SSI. Groin infection rate was higher in the TMP-SMX group (15.4% versus 30.5%, respectively, p=0.022). When adjusting for gender, groin infection was more common in the TMP-SMX group (Odds Ratio 2.5, 95% CI 1.1 -5.4). The groin SSI rate was higher after elective surgery in the TMP-SMX group (13.0% versus 27.8%, respectively, p=0.027), and also after adjusting for gender (Odds Ratio 2.6, 95% CI 1.1 -6.2). The change in antibiotic prophylaxis from Cloxacillin/Cefotaxime to TMP-SMX was associated with an increased rate of inguinal SSI in patients undergoing lower extremity revascularization, despite a possible Hawthorne effect.

Background: No studies have examined long-term risks for aortic aneurysm (AA) and aortic dissection (AD) or mortality after AA or AD hospitalization among patients with type 2 diabetes mellitus (T2DM)., Methods and Results: In this observational cohort study, we linked data for patients with T2DM in the Swedish National Diabetes Register, and 5 individually matched population-based control subjects (CSs) without diabetes mellitus (on the basis of sex, age, and county), to other national databases to capture hospitalizations and death. We examined the risk of hospitalization for AA and AD, as well as mortality risk after AA and AD using Kaplan-Meier curves and Cox regression hazards models. Data on 448 319 patients with T2DM and 2 251 015 CSs were obtained between 1998 and 2015. Mean follow-up time was 7.0 years for the T2DM group and 7.2 years for the CS group. Patients with T2DM had a relative risk reduction of 28% (hazard ratio, 0.72; 95% confidence interval, 0.68-0.76; P <0.0001) for AA and a 47% relative risk reduction (hazard ratio, 0.53; 95% confidence interval, 0.42-0.65; P <0.0001) for AD compared with CSs. Patients with T2DM had a relative risk reduction of 12% (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P <0.0001) for mortality after hospitalization for AA, and unaltered risk (hazard ratio, 1.07; 95% confidence interval, 0.85-1.34; P =0.5859) for mortality after AD, up to 2 years compared with CSs., Conclusions: Patients with T2DM had significantly reduced risks of AA and AD as well as reduced risk of mortality after hospitalization for AA, compared to CS. Data suggest that glycated cross-links in aortic tissue may play a protective role in the progression of aortic diseases among patients with T2DM., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Purpose of Review: Diagnosis of acute mesenteric ischemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischemia may be treated with urgent intestinal revascularization., Recent Findings: The establishment of a hybrid operation room is most important to be able to perform explorative laparotomy for evaluation of the extent of mesenteric ischemia and successful intestinal revascularization. Endovascular recanalization and stenting has become an important alternative, especially in patients with both acute and chronic thrombotic superior mesenteric artery (SMA) occlusion. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. The concept of damage-control surgery is recommended after intestinal revascularization., Summary: Intestinal revascularization in patients with arterial occlusive mesenteric ischemia reduces bowel morbidity and mortality. Observational studies report that both endovascular and open vascular therapy options are effective, but endovascular technique may be preferred in these often elderly and fragile patients.

Introduction: The Basic Surgical Skills course uses an assessment score interval of 0-3. An extended score interval, 1-6, was proposed by the Swedish steering committee of the course. The aim of this study was to analyze the trainee scores in the current 0-3 scored version compared to a proposed 1-6 scored version., Methods: Sixteen participants, seven females and nine males, were evaluated in the current and proposed assessment forms by instructors, observers, and learners themselves during the first and second day. In each assessment form, 17 tasks were assessed. The inter-rater reliability between the current and the proposed score sheets were evaluated with intraclass correlation (ICC) with 95% confidence intervals (CI)., Results: The distribution of scores for 'knot tying' at the last time point and 'bowel anastomosis side to side' given by the instructors in the current assessment form showed that the highest score was given in 31 and 62%, respectively. No ceiling effects were found in the proposed assessment form. The overall ICC between the current and proposed score sheets after assessment by the instructors increased from 0.38 (95% CI 0.77-0.78) on Day 1 to 0.83 (95% CI 0.51-0.94) on Day 2., Discussion: A clear ceiling effect of scores was demonstrated in the current assessment form, questioning its validity. The proposed score sheet provides more accurate scores and seems to be a better feedback instrument for learning technical surgical skills in the Basic Surgical Skills course.

Background: To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register., Methods: We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA., Results: We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA., Conclusions: Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to assess cardiovascular predictors for all-cause long-term mortality in patients undergoing standard endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Consecutive patients treated with EVAR (Zenith(®) stent grafts; Cook) between May 1998 and February 2006 were prospectively enrolled in a computerized database, together with retrospectively collected data on medication, and electrocardiographic and echocardiographic variables. Mortality was assessed on 1 December 2010. The median follow-up time was 68 months and the median age was 74 years (range 53-89) for the 304 patients. Mortality at the end of follow-up was 54.3% (165/304). The proportion of deaths caused by vascular diseases was 61% (101/165). In the univariate analysis, low preoperative ejection fraction (EF) (p = 0.004), absence of statin medication (p = 0.007), and medication with diuretics (p = 0.028) or digitalis (p = 0.016) were associated with an increased long-term mortality rate. Myocardial ischemia on electrocardiogram (ECG) (hazard ratio (HR) 1.6 [95% CI 1.1-2.4]) and anemia (HR 1.5 [95% CI 1.0-2.1]) were found to be independent predictors for long-term mortality after Cox regression analysis. There was a trend that chronic kidney disease, stage ≥ 3 (HR 1.5 [95% CI 1.0-2.2]), and age 80 years and above (HR 1.5 [95% CI 1.0-2.4]) were independently associated with long-term mortality. In conclusion, ischemia on ECG and anemia were independently related to an increased long-term mortality rate after EVAR, and these predictive factors seem to be most important for critical assessment in the preoperative medical work-up.

Background: Thrombolysis is a common method in the treatment of lower extremity bypass graft occlusion. The purpose of this study was to investigate the results of thrombolytic therapy in the management of acute bypass graft occlusion and to identify risk factors for technical failure and amputation., Methods: All patients at two tertiary referral centers undergoing thrombolysis for acute graft occlusion in the lower limb between January 1, 2000 and December 31, 2008 were retrospectively reviewed. Factors associated with technical failure of thrombolytic therapy, major amputation, and mortality were determined with multivariate analysis, and long-term outcomes were assessed with the Kaplan-Meier method and log-rank test., Results: During the study period, 123 patients underwent thrombolysis for acute bypass graft occlusion. Mean age was 69 years (range, 27-91 years); 38% were women. Sixty-seven percent had synthetic grafts. Acute critical leg ischemia (74%) was the dominating symptom preceding thrombolytic treatment. In 29% of cases, no adjunctive interventions were required, whereas 21% underwent open surgery, 39% endovascular intervention, and 11% underwent a hybrid procedure. Technical failure of thrombolysis occurred in 18 patients. Presence of ischemic heart disease (P = .013), older grafts (P = .014), and synthetic grafts (trend; P = .092) were associated with success of thrombolysis, and ischemic heart disease remained as an independent factor in the multivariate analysis for technical success of thrombolysis (P = .04; odds ratio 4.0; 95% confidence interval [CI; 1.1-15.1]), whereas there was a trend for older grafts (P = .089). Mean follow-up was 38 months (range, 0-119 months). The major amputation rate was 11% (14/123) at 1 month and 25% (31/122) at 1 year. In a Cox regression model, technical failure (P = .031; hazard ratio [HR] 2.58, 95% CI [1.0-6.08]), higher age (P = .004; HR 1.06, 95% CI [1.02-1.10]), and synthetic graft as opposed to vein graft (P = .050; HR 2.63, 95% CI [1.0-6.9]) remained as independent factors associated with major amputation. The amputation-free survival rate was 89% and 75% at 1 and 12 months, respectively. Higher age (P < .001; HR 1.06, 95% CI [1.03-1.09]) and acute limb ischemia (P = .007; HR 2.40, 95% CI [1.26-4.56]) remained as independent adverse factors associated with amputation-free survival., Conclusions: Our findings support the use of thrombolysis in the treatment of acute bypass graft occlusion in the lower limb given its acceptable short- and long-term amputation-free survival rates. Technical failure and higher age were factors associated with major amputation. Synthetic grafts appeared to have a somewhat increased likelihood of technically successful thrombolysis compared with vein grafts, but on the other hand, they exhibited an increased risk of amputation during follow-up., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Acute thromboembolic occlusion of the superior mesenteric artery (SMA) is associated with high mortality. Recent advances in diagnostics and surgical techniques may affect outcome., Methods: Through the Swedish Vascular Registry (Swedvasc), 121 open and 42 endovascular revascularizations of the SMA at 28 hospitals during 1999 to 2006 were identified. Patient medical records were retrieved, and survival was analyzed with multivariate Cox-regression analysis., Results: The number of revascularizations of the SMA increased over time with 41 operations in 2006, compared to 10 in 1999. Endovascular approach increased sixfold by 2006 as compared to 1999. The endovascular group had thrombotic occlusion (P < .001) and history of abdominal angina (P = .042) more often, the open group had atrial fibrillation more frequently (P = .031). All the patients in the endovascular group, but only 34% after open surgery, underwent completion control of the vascular reconstruction (P < .001). Bowel resection (P < .001) and short bowel syndrome (SBS; P = .009) occurred more frequently in the open group. SBS (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.3-5.0) and age (HR, 1.03/year; 95% CI, 1.00-1.06) were independently associated with increased long-term mortality. Thirty-day and 1-year mortality rates were 42% vs 28% (P = .03) and 58% vs 39% (P = .02), for open and endovascular surgery, respectively. Long-term survival after endovascular treatment was better than after open surgery (log-rank, P = .02)., Conclusion: The results after endovascular and open surgical revascularization of acute SMA occlusion were favorable, in particular among the endovascularly treated patients. Group differences need to be confirmed in a randomized trial., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: This study was designed to assess endovascular intervention for central venous cannulation in patients with vascular occlusion after previous catheterization., Methods: Patients referred for endovascular management of central venous occlusion during a 42-month period were identified from a regional endovascular database, providing prospective information on techniques and clinical outcome. Corresponding patient records, angiograms, and radiographic reports were analyzed retrospectively., Results: Sixteen patients aged 48 years (range 0.5-76), including 11 females, were included. All patients but 1 had had multiple central venous catheters with a median total indwelling time of 37 months. Eleven patients cannulated for hemodialysis had had significantly fewer individual catheters inserted compared with 5 patients cannulated for nutritional support (mean 3.6 vs. 10.2, p<0.001) before endovascular intervention. Preoperative imaging by magnetic resonance tomography (MRT) in 8 patients, computed tomography (CT) venography in 3, conventional angiography in 6, and/or ultrasonography in 8, verified 15 brachiocephalic, 13 internal jugular, 3 superior caval, and/or 3 subclavian venous occlusions. Patients were subjected to recanalization (n=2), recanalization and percutaneous transluminal angioplasty (n=5), or stenting for vena cava superior syndrome (n=1) prior to catheter insertion. The remaining 8 patients were cannulated by avoiding the occluded route., Conclusions: Central venous occlusion occurs particularly in patients under hemodialysis and with a history of multiple central venous catheterizations with large-diameter catheters and/or long total indwelling time periods. Patients with central venous occlusion verified by CT or MRT venography and need for central venous access should be referred for endovascular intervention.

Background: In 1992, there were major changes in Swedish law of the deceased, which had led to a dramatic decrease in autopsy rates. The aim of this study was to investigate the prevalence of fatal or potential fatal surgical diseases within a Swedish forensic autopsy cohort, before and after this change in legislation., Methods: Deaths referred for forensic autopsy at the Institution of Forensic Medicine, Lund University Hospital, Sweden, between 1970-1982 and 2000-2004, were studied regarding the prevalence of aorto-iliac diseases, acute abdomen and abdominal cancer., Results: The forensic autopsy rates in the population during the two time periods were 14.0% (29 399 patients) and 5.3% (4487 patients), respectively. The total prevalence of surgical diseases has increased significantly from 67.3 (95% confidence interval 64.3-70.2) to 83.4 (74.9-91.8) per 1000 autopsies, respectively. The cause-specific mortality ratios in patients with fatal acute abdomen increased significantly from 16.5 (15.1-18.0) to 39.0 (33.2-44.8) per 1000 autopsies, respectively, and there was almost a three-time increase in patients with fatal gastrointestinal haemorrhage and acute alcohol-related pancreatitis., Conclusion: Forensic autopsy data continues to be invaluable, despite changes in legislation in Sweden, for epidemiological studies on fatal or potential fatal surgical diseases.

Objective: The aim of the present population-based study was to assess the trends of age- and gender-specific incidence of ruptured abdominal aortic aneurysm (rAAA)., Methods: Patients with rAAA from the city of Malmö, Sweden, were studied between 2000 and 2004. An analysis of trends of incidence and mortality of rAAA in Malmö was possible because of a previous population-based study on patients with rAAA between 1971 and 1986 (autopsy rate 85% compared with 25% for the time period 2000 to 2004). The in-hospital registry of Malmö University Hospital and the databases at the Department of Pathology, Malmö, and the Institution of Forensic Medicine, Lund, identified patients with rAAA, and the in-hospital registry identified all elective repairs for AAA., Results: Compared with the time period 1971 to 1986, the overall incidence of rAAA significantly increased from 5.6 (95 % confidence interval [CI], 4.9 to 6.3) to 10.6 (95% CI, 8.9 to 12.4) per 100,000 person-years (standardized mortality ratio, 1.6; 95% CI, 1.0 to 2.1). In men aged 60 to 69 and 70 to 79 years, the incidence increased significantly from 16 (95% CI, 11 to 21) and 56 (95% CI, 43 to 69) to 46 (95% CI, 28 to 63) and 117 (95% CI, 84 to 149) per 100,000 person-years, respectively, whereas no increase in the age-specific incidence in women could be demonstrated. The overall incidence of elective repair of AAA increased significantly from 3.4 (95% CI, 2.8 to 4.0) to 7.0 (95% CI, 5.6 to 8.4) per 100,000 person-years and increased most significantly from 12 (95% CI, 3.4 to 32) to 68 (95% CI, 34 to 102) per 100,000 person-years in men aged 80 to 89 years and from 5.1 (95% CI, 2.4 to 9.3) to 28 (95% CI, 15 to 41) per 100,000 person-years in women aged 70 to 79 years. The elective-acute repair ratio in women increased from 2.4 to 5.6 and decreased in men from 2.1 to 1.0., Conclusions: Between 1971 to 1986 and 2000 to 2004, the incidence of rAAA increased significantly, despite a 100% increase in elective repairs and notwithstanding a potential for bias towards underestimation due to lower autopsy rates in recent years. The reason behind this increase is unclear, and further studies are needed to identify risk groups for direction of effective prevention and screening.