Search

Tämän väitöstutkimuksen tarkoituksena oli tutkia ja kuvata alaraajojen pitkäaikaiseen valtimoverenkiertohäiriöön (krooninen alaraajaiskemia) liittyviä ilmiöitä, joihin on toistaiseksi kiinnitetty vähän huomiota. Erityisesti haluttiin selvittää kroonisen alaraajaiskemian osuutta tasapainonhallinnan heikkenemisessä vanhuksilla. Lisäksi tutkittiin kroonisen alaraajaiskemian yleisyyttä ja piirteitä 90 vuotta täyttäneillä henkilöillä sekä selvitettiin kohonneen nilkka olkavarsipaineindeksin (ABI) merkitystä kroonisen alaraajaiskemian diagnostiikassa. Kroonisen alaraajaiskemian ja tasapainonhallinnan välistä yhteyttä tutkittiin kahden laajan väestön terveyttä ja toimintakykyä selvittävän tutkimuksen (Ikivihreät tutkimus, Terveys 2000 tutkimus) tasapainomittausten tuloksia analysoimalla. Molemmissa tutkimuksissa tasapainomittaukset tehtiin voimalevyllä kehon huojuntaa mittaavissa tasapainotesteissä. Tulokset niin poikkileikkaus kuin pitkittäistutkimuksessakin viittaavat siihen, että krooniseen alaraajaiskemiaan liittyy merkittävää tasapainonhallinnan heikkenemistä. Kroonisen alaraajaiskemian yleisyyttä 90 vuotta täyttäneillä vanhuksilla selvitettiin vuonna 1914 syntyneiden jyväskyläläisten keskuudessa (Ikivihreät seuruututkimus 2004). Kroonisen alaraajaiskemian yleisyys oli 22 %. Sairaus ilmeni pääasiassa oireettomana. Lisäksi noin kolmanneksella tutkituista todettiin koholla oleva ABI. Tutkittavat, joilla oli matala (1.4) ABI ilmoittivat keskimääräistä enemmän vaikeuksia liikkumisessa verrattuna henkilöihin, joilla oli normaali ABI. Tulokset eivät kuitenkaan olleet tilastollisesti merkitseviä. Poikkeavaan ABI arvoon liittyi sen sijaan merkittävästi kohonnut riski kuolla vuoden kuluessa mittaustilanteesta. Kohonneen ABI: n yleisyys verisuonikirurgin vastaanotolle (TAYS 2002 2006) lähetettyjen potilaiden keskuudessa oli 8.4 % ja varvaspainemittauksella tai varjoainekuvauksella varmistetun kroonisen alaraajaiskemian vallitsevuus tässä alaryhmässä oli noin 70 %. Krooninen alaraajaiskemia oli yleisempää tupakoitsijoilla sekä potilailla, jotka sairastivat kroonista munuaisten vajaatoimintaa tai sepelvaltimotautia. Kroonisen alaraajaiskemian ja tasapainonhallinnan välistä yhteyttä on tutkittu riittämättömästi. Mahdollisella syy seuraussuhteen toteamisella olisi merkitystä varhaiskuntoutuksen ja ohjauksen kannalta, sillä tasapainonhallinnalla on keskeinen rooli riittävän liikunta- ja toimintakyvyn takaajana. Kroonista alaraajaiskemiaa sairastavat potilaat ovat yleensä oireettomia, ts. heillä ei ole katkokävelyoiretta tai viitteitä kriittisestä iskemiasta (leposärky haavauma, kuolio). Diagnoosin kannalta oleellista onkin alaraajojen valtimoverenpaineen mittaus ja nilkka olkavarsipaineindeksin (ankle brachial systolic pressure index, ABI) määrittäminen. ABI?0.90 pidetään yleisesti alaraajaiskemian diagnostisena rajana. Kohonneen paineindeksin (ABI>1.4) kliinisestä merkityksestä on vähän tietoa. Viimeaikaiset tutkimustulokset viittaavat kuitenkin siihen, että kohonneeseen paineindeksiin liittyy lähes yhtä merkittävä kuolemanriski kuin alentuneeseen ABI arvoon. Hyvin iäkkäiden (90 vuotta täyttäneiden) sairastuvuudesta krooniseen alaraajaiskemiaan ei ole aiempia julkaisuja. Tutkimustulokset osoittavat, että kroonisen alaraajaiskemian seurauksena kehittyy merkittävää tasapainonhallinnan heikkenemistä. Tämä tieto auttaa terveydenhuollon ammattilaisia tunnistamaan henkilöt, joilla on kohonnut riski liikuntakyvyn huononemiselle ja tämän seurauksena laitoshoitoon siirtymiselle. Tutkimuksessa voitiin lisäksi osoittaa, että krooninen alaraajaiskemia on yleinen, joskin pääasiassa oireeton, sairaus 90 vuotta täyttäneillä vanhuksilla. Tutkimuksen perusteella ei kuitenkaan pystytä tekemään luotettavia johtopäätöksiä kroonisen alaraajaiskemian ja toimintakyvyn välisestä yhteydestä hyvin iäkkäillä. Tutkimustulokset viittaavat myös siihen, että ABI mittauksessa saatuja tuloksia voisi käyttää kroonisen alaraajaiskemian diagnostiikassa perinteistä käsitystä laajemmin. Tiedolla on käytännön merkitystä erityisesti perusterveydenhuollon yksiköissä, joissa kroonisen alaraajaiskemian diagnosointi perustuu kliinisen tutkimuksen ohella nimenomaan ABI mittaukseen. The risk factors, typical symptoms (intermittent claudication, critical limb ischaemia) and treatment of peripheral arterial disease (PAD) are widely studied and well-known to clinicians. The role of elevated ankle-brachial index (ABI) in the process of diagnosing PAD and the prevalence and clinical features of PAD in nonagenarians are, however, unknown. In addition, the relationship between PAD and functional decline has attracted little attention until recently. We therefore began to pursue more knowledge about factors underlying or indicating PAD in older people and to describe functional decline in peripheral arterial disease. The association of elevated ABI and PAD was assessed in a clinical sample of 1,762 patients admitted to the vascular outpatient clinic by comparing the ABI and TBI results, in addition to determining further which factors were significantly associated with PAD among those with elevated ABI. The role of PAD among nonagenarians was evaluated in a cohort of 90-year-old individuals (N=58) by measuring ABI and inquiring about their mobility level. In a subgroup of participants, lower extremity functional status was measured by performing walking tests. The association of PAD and mortality among nonagenarians was also assessed during a one-year follow-up. The relationship between PAD and impaired balance was evaluated both cross-sectionally and longitudinally by using standardized force platform balance tests. The results of two population-based studies (The Evergreen project [N=419] and the Health 2000 survey [N=1323]) were analyzed for this purpose. The prevalence of elevated ABI among patients admitted to the vascular outpatient clinic was 8.4% and that of PAD among them 62% 84% depending on the cut-off value (1.3¬¬ 1.5). PAD was significantly more probable among those with chronic renal failure, a history of smoking and coronary heart disease (CHD). The specificity of elevated ABI (≥ 1.3) in identifying patients with PAD seems to be good, whereas its sensitivity in excluding the disease is only satisfactory. Among nonagenarians, PAD was mainly asymptomatic, with a prevalence of 22%. Moreover, approximately one third of them presented with elevated ABI. Nonagenarians with a low (1.4) ABI reported more difficulties in the physical activities of daily living (PADL tasks) than those with normal ABI, but the results did not reach statistical significance. Furthermore, an abnormal ABI was shown to correlate with poorer one-year survival among the subjects. The results also implied that PAD is associated with poorer balance performance both cross-sectionally and longitudinally. In the cross-sectional analysis, the presence of diabetes exacerbated the deterioration in balance but alone affected balance somewhat less than PAD. The utility of ABI in diagnosing PAD seems to be more wide-ranging than the traditional conception presumes. In addition, PAD, even though mainly asymptomatic, continues to affect the life of nonagenarians. However, more studies are required to determine the possible relationship between PAD and mobility loss in very old people. The fact that PAD is associated with poorer balance gives the clinician a tool for recognizing those possibly at greater risk for mobility loss and nursing home placement.

Objective The ideal stent combination for chimney endovascular aneurysm repair remains undetermined. Therefore, we sought to identify optimal aortic and chimney stent combinations that are associated with the best outcomes by analyzing the worldwide collected experience in the PERformance of chImney technique for the treatment of Complex aortic pathoLogiES (PERICLES) registry. Methods The PERICLES registry was reviewed for patients with pararenal aortic disease electively treated from 2008 to 2014. Eleven different aortic devices were identified with three distinct subgroups: group A (n = 224), nitinol/polyester; group B (n = 105), stainless steel/polyester; and group C (n = 69), nitinol/expanded polytetrafluoroethylene. The various chimney stent subtypes included the balloon-expandable covered stent (BECS), self-expanding covered stent, and bare-metal stent. Deidentified aortic and chimney device combinations were compared for risk of chimney occlusion, type IA endoleak, and survival. Effects of high-volume centers (>100 cases), use of an internal lining chimney stent, number of chimney stents, and number of chimney stent subtypes deployed were also considered. We considered demographics, comorbidities, and aortic anatomic features as potential confounders in all models. Results The 1- and 3-year freedom from BECS chimney occlusion was not different between groups (group A, 96% ± 2% and 87% ± 5%; groups B and C, 93% ± 3% and 76% ± 10%; Cox model, P = .33). Similarly, when non-BECS chimney stents were used, no difference in occlusion risk was noted for the three aortic device groupings; however, group C patients receiving BECS did have a trend toward higher occlusion risk relative to group C patients not receiving a BECS chimney stent (hazard ratio [HR], 4.0; 95% confidence interval [CI], 0.85-18.84; P = .08). Patients receiving multiple chimney stents, irrespective of stent subtype, had a 1.8-fold increased risk of occlusion for each additional stent (HR, 1.8; 95% CI, 1.2-2.9; P = .01). Use of a bare-metal endolining stent doubled the occlusion hazard (HR, 2.1; 95% CI, 1.0-4.5; P = .05). Risk of type IA endoleak (intraoperatively and postoperatively) did not significantly differ for the aortic devices with BECS use; however, group C patients had higher risk relative to groups A/B without BECS (C vs B: odds ratio [OR], 3.2 [95% CI, 1-11; P = .05]; C vs A/B: OR, 2.4 [95% CI, 0.9-6.4; P = .08]). Patients treated at high-volume centers had significantly lower odds for development of type IA endoleak (OR, 0.2; 95% CI, 0.1-0.7; P = .01) irrespective of aortic or chimney device combination. Mortality risk was significantly higher in group C + BECS vs group A + BECS (HR, 5.3; 95% CI, 1.6-17.5; P = .006). The 1- and 3-year survival for groups A, B, and C (+BECS) was as follows: group A, 97% ± 1% and 92% ± 3%; group B, 93% ± 3% and 83% ± 7%; and group C, 84% ± 7% and 63% ± 14%. Use of more than one chimney subtype was associated with increased mortality (HR, 3.2; 95% CI, 1.4-7.5; P = .006). Conclusions Within the PERICLES registry, use of nitinol/polyester stent graft devices with BECS during chimney endovascular aneurysm repair is associated with improved survival compared with other aortic endografts. However, this advantage was not observed for non-BECS repairs. Repairs incorporating multiple chimney subtypes were also associated with increased mortality risk. Importantly, increasing chimney stent number and bare-metal endolining stents increase chimney occlusion risk, whereas patients treated at low-volume centers have higher risk of type IA endoleak.

Objective Endovascular aneurysm repair (EVAR) with the chimney technique (ch-EVAR) has been used for the treatment of aortic aneurysms as an alternative approach to fenestrated endografting or open repair. Nonetheless, the need for an upper extremity arterial access may contribute to a higher risk for periprocedural cerebrovascular events. This study reports on the perioperative cerebral and major adverse cardiac and cerebrovascular events (MACCE) after ch-EVAR. Methods The PERICLES registry (PERformance of the chImney technique for the treatment of Complex aortic pathoLogiES) is an international, retrospective multicenter study evaluating the performance of ch-EVAR for the treatment of complex aortic pathologies. For the purpose of the current analysis, 425 patients treated by ch-EVAR between 2008 and 2014 were included. The primary outcome of this analysis was the incidence of procedure related cerebrovascular events defined as transient ischemic attack or stroke. The secondary end point was in-hospital MACCE, including acute coronary syndrome, stroke, and death of any cause. Results The incidence of clinical relevant cerebrovascular events was 1.9% (8/425). A postoperative transient ischemic attack was observed in four patients (0.95%) and a stroke in additional four (0.95%). Three patients died during the hospital stay secondary to sequelae from postoperative stroke. A prior history of stroke/transient ischemic attack, atrial fibrillation, previous carotid revascularization, or known carotid artery disease did not significantly increase the risk for adverse neurologic events. The overall MACCE rate amounted to 8.5% (36/425). Logistic regression analysis revealed that the use of bilateral upper extremity access (odds ratio [OR], 2.79; 95% confidence interval [CI], 1.04-7.45]), aneurysm rupture (OR, 5.33; 95% CI, 1.74-16.33), and a prolonged operation time (>290 minutes; OR, 1.005; 95% CI, 1.001-1.008) were associated with a significantly increased risk for MACCE. Conclusions This analysis demonstrates that ch-EVAR is associated with a relatively low rate of cerebrovascular events. However, a postoperative stroke is associated with increased mortality. Ruptured aneurysms, bilateral upper extremity access as in case of multiple chimney graft placement, and longer operative times were identified as independent risk factors for MACCE.