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Category: Bunion Introduction/Purpose: Fusion of the first tarsometatarsal joint is common for the treatment of moderate to severe hallux abductovalgus deformity. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. The addition of a screw from the 1st metatarsal base to the 2nd metatarsal base allows for increased stability and can help create a “spot weld” between the metatarsal bases to prevent loss of deformity correction. The additional screw construct is termed the intermetatarsal screw in this study. The purpose of the current study is to determine the long-term maintenance of angular correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis with the addition of the intermetatarsal screw. Methods: A retrospective, single-center chart and radiographic review was performed of 17 consecutive patients who underwent primary hallux abductovalgus correction with a 1st tarsometatarsal joint arthrodesis using the intermetatarsal screw fixation by the senior author. The study period was from January 1, 2017 to May 14, 2018. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain film radiographs. Preoperative films were used if they were within 3 months of the surgery and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal angle, hallux abductus angle, and tibial sesamoid position. Results: 17 consecutive patients were identified for review that met inclusion criterea. Mean follow up time was 8.12 months (SD ± 3.68). Bony union was achieved in all patients. There was 1 symptomatic recurrent bunion, 1 case of symptomatic hardware, and 1 case of transient neuritis. Average preoperative IMA was 16.05º (±2.34), HAA was 33.05º (±6.24), and tibial sesamoid position was 5.77 (±0.9). Average IMA improvement was 8.38º (±2.21), HAA improvement was 17.25º (±8.21), and TSP improvement was 3.29 (±1.36) positions. Average loss of IMA was 1.03º (±1.24), HAA was 4.14º (±5.34), and tibial sesamoid position was 0.65 (±0.86) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters; both in initial improvements and loss of correction (pConclusion: The current study shows the addition of an intermetatarsal screw for 1st tarsometatarsal joint arthrodesis has good union rates, a low complication rate, and maintains correction. Further clinical and comparative studies with a larger patient cohort may yield additional useful information.

Category: Bunion Introduction/Purpose: The Lapidus procedure is common for the treatment of moderate to severe hallux abductovalgus deformity. Standard fixation consists of a combination of crossing screws and plates. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. This construct is termed the cross screw intermediate cuneiform construct. The purpose of this study is to determine the long-term angular maintained correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis utilizing the cross screw intermediate cuneiform construct to correct and maintain the hallux abductovalgus deformity. Methods: A retrospective, single-center chart and radiographic review was performed of all patients with HAV treated with a 1st tarsometatarsal joint arthrodesis with cross screw intermediate cuneiform construct fixation by the senior author. The study period was from June 1st, 2016 to June 1st, 2017. Patients who underwent 1st tarsometatarsal joint arthrodesis for a primary diagnosis of HAV were studied. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain films radiographs. Preoperative films were used if they were within 3 months of the surgery, and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal ankle, hallux abductus angle, and tibial sesamoid position. Results: Forty-five patients met inclusion criteria and were included in the study. Mean follow-up time was 9.76 months (SD ± 7.62). Bony union was achieved in 43 of 45 patients (95.6%). Two patients required revision bunionectomy as result of recurrence (4.4%). Other complications included symptomatic hardware in 2 patients requiring hardware removal and neuritis in 2 patients. Average preoperative IMA was 15.95º (±2.55), HAA was 31.14º (±6.19), and tibial sesamoid position was 4.36 (±1.07). Final average improvement of IMA was 6.26º (±2.9), HAA was 13.89º (±7.02), and tibial sesamoid position was 2.07 (±1.34) positions. Average loss of IMA correction was 1.70º (±1.64), HAA was 2.45º (±4.6), and tibial sesamoid position was 0.8 (±0.82) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters both in initial improvements and loss of correction (pConclusion: The current study shows the cross screw intermediate cuneiform construct for 1st tarsometatarsal joint arthrodesis has good union rates, a low complication rate, and maintains correction. Further clinical and comparative studies may yield additional useful information.

Category: Hindfoot Introduction/Purpose: Autogenous bone graft remains the standard bone graft in foot and ankle surgery when filling a bone void or adding biology to an arthrodesis site. Harvesting autograft can have serious donor site morbidity with an average complication rate of 8% and reports as high as 25%. Complications range from persistent pain to severe infection. Most procedures in the foot and ankle require only a small volume of graft. Using a small reaming graft harvester, surgeons can harvest autograft from the ipsilateral calcaneus. This is done within the same surgical field and requires minimal additional operative time. The purpose of this article is to review a population of patients who underwent calcaneal autograft harvesting with a reaming graft harvester and evaluate the outcomes of the procedure. Methods: From August 2015 to February 2018, all patients who underwent calcaneal autograft harvesting by a single surgeon were identified and reviewed. Patients were included if they had autograft harvested from the calcaneus on the ipsilateral operative limb using a reamer bone graft harvester and if they had complete clinical follow up of at least 6 months. Patients were excluded if they had autograft from a site other than the ipsilateral calcaneus, had a previous harvest from the ipsilateral calcaneus, or if they did not have full follow up of at least 6 months. Outcomes of interest were major and minor complications, intra- operative complications, and long term radiographic findings. Patients required graft for numerous primary procedures including a variety of arthrodesis or filling of bone voids. Postoperative protocols and return to weightbearing times varied with the accepted protocols for the primary procedure. Results: 300 patients were identified and met inclusion criteria. Average follow up was 12.6 months. There was 1 major complication (0.3%) consisting of a calcaneal stress fracture that healed with a period of 4 weeks of non weightbearing followed by 4 weeks of protected weightbearing. There were 3 minor complications (1%) consisting of transient painful scar and medial heel pain that all resolved uneventfully. There were no intraoperative complications while performing the 300 procedures. There were no incidences of neurovascular damage. Of the patients with over 1 year radiographic follow up, all harvest sites were still visible on lateral plain film radiographs. Conclusion: Using a small reamer to harvest calcaneal autograft for foot and ankle surgeries that require a small to moderate amount of bone graft is safe and effective. Approximately 4 cc of graft can be harvested very quickly without needing to prepare another surgical site for harvesting. The complication rate for harvesting calcaneal autograft was found to be extremely low in this study, despite the harvest site remaining visible on radiographs past 1 year. The proposed technique can be extremely useful to the foot and ankle surgeon.

This study aimed to assess the ecotoxicological effects of the interaction of fullerene (C60) and benzo[a]pyrene (B[a]P) on the marine mussel, Mytilus galloprovincialis. The uptake of nC60, B[a]P and mixtures of nC60 and B[a]P into tissues was confirmed by GC-MS, LC-HRMS and ICP-MS. Biomarkers of DNA damage as well as proteomics analysis were applied to unravel the toxic effect of B[a]P and C60. Antagonistic responses were observed at the genotoxic and proteomic level. Differentially expressed proteins (DEPs) were only identified in the B[a]P single exposure and the B[a]P mixture exposure groups containing 1 mg/L of C60, the majority of which were down-regulated (~52%). No DEPs were identified at any of the concentrations of nC60 (p < 0.05, 1% FDR). Using DEPs identified at a threshold of (p < 0.05; B[a]P and B[a]P mixture with nC60), gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis indicated that these proteins were enriched with a broad spectrum of biological processes and pathways, including those broadly associated with protein processing, cellular processes and environmental information processing. Among those significantly enriched pathways, the ribosome was consistently the top enriched term irrespective of treatment or concentration and plays an important role as the site of biological protein synthesis and translation. Our results demonstrate the complex multi-modal response to environmental stressors in M. galloprovincialis.

This longitudinal cohort study analyzes data collected across 11 years to assess the association between the presence and severity of atopic dermatitis in children and maternal sleep disturbance among a population-based UK cohort of mother-child pairs., Key Points Question Do mothers of children with atopic dermatitis experience sleep disturbances, and to what extent are these explained by child sleep disturbances? Findings In this cohort study of 11 649 mother-child pairs, sleep disturbances were common among mothers of children with atopic dermatitis followed up from birth through age 11 years. Having a child with atopic dermatitis was significantly associated with impaired maternal sleep quality, subjectively insufficient sleep, and increased daytime exhaustion; however, child sleep disturbances did not fully explain maternal sleep disturbances. Meaning Clinicians caring for children with atopic dermatitis should screen for maternal sleep disturbances and caregiver fatigue., Importance The well-being and development of children is strongly influenced by parents’ physical and psychosocial health. Data from small, clinic-based studies suggest that sleep loss may be common in parents of children with atopic dermatitis (AD), but longitudinal population-based studies are lacking. Objectives To compare sleep disturbances over time between mothers of children with and without AD and to determine whether these disturbances are associated with the child’s disease severity and the child’s sleep disturbances. Design, Setting, and Participants In the ongoing Avon Longitudinal Study of Parents and Children, all pregnant women residing in Avon, United Kingdom, with an expected delivery date between April 1, 1991, and December 31, 1992, were recruited. Analyses for this study, a secondary analysis of this cohort, were performed from September 2017 to September 2018. Mother-child pairs were followed up with a time-varying measure of child AD activity and severity and self-reported maternal sleep measures repeated at multiple time points between child ages 6 months and 11 years. Main Outcomes and Measures Time-varying binary measures of maternal sleep duration (

The treatment of hallux abductovalgus continues to evolve as surgeons better understand first ray biomechanical pathology. Many authors have advocated the use of the 1st tarsometatarsal joint arthrodesis for correction of moderate to severe hallux abductovalgus deformities and those with hypermobility of the 1st ray. There continues to be debate over the best surgical technique, fixation construct, and post operative protocol for the 1st tarsometatarsal joint fusion. We describe a technique with a unique hardware construct that is reproducible and allows for excellent deformity correction and pain relief while minimizing associated complications with this procedure.

Toxic metal reduction is at the forefront of many design considerations today, additive manufacturing has the ability to combine materials in ways other traditional processes cannot and has the potential to offer unique solutions to reduce hazardous materials needed in manufacturing. Tungsten carbide (WC) has been used as a substitute in wear applications where toxic processes are traditionally utilized, but it can be difficult to deposit high-quality, hard and durable coatings. Additionally, there is a need to apply WC coatings on surfaces not feasible with the current processes. Cold spray, a solid-state directed powder deposition process, is effective at depositing carbides, though powders must be thoughtfully designed to achieve desired mechanical properties. In this study, WC was investigated as a hard chrome alternative for wear applications. Various blend ratios and preparation methods were evaluated as feedstock powder and then sprayed. Feedstock characteristics were compared to cold spray performance. Cold spray consolidations were evaluated for coating porosity and hardness. It was found that when powder make-up and composition were optimized, a high-hardness and low-porosity material was made that will contribute to the reduction in dependency of Cr in wear-facing components.

Machining and surface finishing is essential in the processing of many ceramics, however, it can be detrimental to subsequent performance as it introduces residual stresses and structural defects. Using micro-Raman spectroscopy the residual stress and crystallinity of hot-pressed SiC tiles were examined after finishing with several different methods. 514 nm and 633 nm lasers in both conventional and confocal settings enabled stress as a function of depth to be assessed. Single crystal, electronics grade SiC was used for comparison. Compressive residual stresses were present at the surface and in the sub-surface region in all the samples, but the surface with lowest roughness and a mirror-like finish had the highest residual stress. Crystallinity in SiC is reduced by defects and stacking faults produced during machining and finishing. The finer surface finishes had higher residual stresses, but were actually found to have better crystallinity than the rough surfaces. The dependence of residual stress and crystallinity on surface roughness is attributed to a change in the mode of ceramic removal from energetic and brittle for rough finishes to ductile for the shallow cuts of smooth finishes. The dependence of stress and crystallinity on roughness means a balance must be struck between smoothness, crystallinity and stresses in choosing the best finish for a given application.

Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was –25° and improved to –5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot.

Atopic dermatitis is a complex disease with differing clinical presentations. Many attempts have been made to identify uniform subtypes, or phenotypes, of atopic dermatitis in order to identify different aetiologies, improve diagnosis, estimate more accurate clinical prognoses, inform treatment andmanagement or predict treatment efficacy andeffectiveness. However, no consensus yet exists on exactly what defines these phenotypes or how many there are and whether they are genuine or statistical artefacts. This review aims to identify previously reported phenotypes of atopic dermatitis, the features used to define them and any characteristics or clinical outcomes significantly associated with them.We will search Ovid Embase, Ovid MEDLINE and Web of Science from inception to the latest available date at the time of the search for studies attempting to classify atopic dermatitis in humans using any cross-sectional or longitudinal epidemiological or interventional design. Primary outcomes are atopic dermatitis phenotypes, features used to define them and characteristics associated with them in subsequent analyses. A secondary outcome is the methodological approach used to derive them. Two reviewers will independently screen titles and abstracts for inclusion, extract data and assess study quality. We will present the results of this review descriptively and with frequencies where possible.Ethical approval is not required for this study as it is a systematic review. We will report results from this systematic review in a peer-reviewed journal. The main value of this study will be to inform further research.CRD42018087500.

Atopic eczema is a common inflammatory skin disease. Various inflammatory conditions have been linked to cardiovascular disease, a major cause of global mortality and morbidity.We sought to systematically review and meta-analyze population-based studies assessing associations between atopic eczema and specific cardiovascular outcomes.MEDLINE, Embase, and Global Health were searched from inception to December 2017. We obtained pooled estimates using random-effects meta-analyses. We used a multivariate Bayesian meta-regression model to estimate the slope of effect of increasing atopic eczema severity on cardiovascular outcomes.Nineteen relevant studies were included. The effects of atopic eczema reported in cross-sectional studies were heterogeneous, with no evidence for pooled associations with angina, myocardial infarction, heart failure, or stroke. In cohort studies atopic eczema was associated with increased risk of myocardial infarction (n = 4; relative risk [RR], 1.12; 95% CI, 1.00-1.25), stroke (n = 4; RR, 1.10; 95% CI, 1.03-1.17), ischemic stroke n = 4; RR, 1.17; 95% CI, 1.14-1.20), angina (n = 2; RR, 1.18; 95% CI, 1.13-1.24), and heart failure (n = 2; RR, 1.26; 95% CI, 1.05-1.51). Prediction intervals were wide for myocardial infarction and stroke. The risk of cardiovascular outcomes appeared to increase with increasing severity (mean RR increase between severity categories, 1.15; 95% credibility interval, 1.09-1.21; uncertainty interval, 1.04-1.28).Significant associations with cardiovascular outcomes were more common in cohort studies but with considerable between-study heterogeneity. Increasing atopic eczema severity was associated with increased risk of cardiovascular outcomes. Improved awareness among stakeholders regarding this small but significant association is warranted.

Summary Background Zoster vaccination was introduced in England in 2013, where tackling health inequalities is a statutory requirement. However, specific population groups with higher zoster burden remain largely unidentified. Objectives To evaluate health inequalities in zoster disease burden prior to zoster vaccine introduction in England. Methods This population‐based cohort study used anonymized U.K. primary care data linked to hospitalization and deprivation data. Individuals aged ≥ 65 years without prior zoster history (N = 862 470) were followed from 1 September 2003 to 31 August 2013. Poisson regression was used to obtain adjusted rate ratios (ARRs) for the association of sociodemographic factors (ethnicity, immigration status, individuals' area‐level deprivation, care home residence, living arrangements) with first zoster episode. Possible mediation by comorbidities and immunosuppressive medications was also assessed. Results There were 37 014 first zoster episodes, with an incidence of 8·79 [95% confidence interval (CI) 8·70–8·88] per 1000 person‐years at risk. In multivariable analyses, factors associated with higher zoster rates included care home residence (10% higher vs. those not in care homes), being a woman (16% higher vs. men), nonimmigrants (~30% higher than immigrants) and white ethnicity (for example, twice the rate compared with those of black ethnicity). Zoster incidence decreased slightly with increasing deprivation (ARR most vs. least deprived 0·96 (95% CI 0·92–0·99) and among those living alone (ARR 0·96, 95% CI 0·94–0·98). Mediating variables made little difference to the ARR of social factors but were themselves associated with increased zoster burden (ARR varied from 1·11 to 3·84). Conclusions The burden of zoster was higher in specific sociodemographic groups. Further study is needed to ascertain whether these individuals are attending for zoster vaccination., What's already known about this topic? Monitoring and reducing health inequalities is a statutory requirement in the U.K.Incidence of herpes zoster is known to be higher among individuals with certain comorbidities and those taking immunosuppressive treatment.In contrast, little is known about the social determinants of zoster, which may contribute to the inequality of zoster disease burden in England. What does this study add? Older individuals at higher risk of zoster included women, those in care homes, those of white ethnicity and nonimmigrants.Individuals with certain comorbidities and taking immunosuppressive therapies were at appreciable increased risk of zoster, but this explained little of the increased risk in the specific demographic and social groups.The findings should inform possible future use of the inactivated zoster vaccine among those at higher risk, including care home residents. https://doi.org/10.1111/bjd.16751 available online https://goo.gl/Uqv3dl

Summary Background Routinely collected electronic health data obtained for administrative and clinical purposes are increasingly used to study atopic dermatitis (AD). Methods for identifying AD patients in routinely collected electronic health data differ, and it is unknown how this might affect study results. Objectives To evaluate how patients with AD have been identified in studies using routinely collected electronic health data, to determine whether these methods were validated and to estimate how the method for identifying patients with AD affected variability in prevalence estimates. Methods We systematically searched PubMed, Embase and Web of Science for studies using routinely collected electronic health data that reported on AD as a primary outcome. Studies of localized AD and other types of dermatitis were excluded. The protocol for this review was registered in PROSPERO (CRD42016037968). Results In total, 59 studies met eligibility criteria. Medical diagnosis codes for inclusion and exclusion, number of occasions of a code, type of provider associated with a code and prescription data were used to identify patients with AD. Only two studies described validation of their methods and no study reported on disease severity. Prevalence estimates ranged from 0·18% to 38·33% (median 4·91%) and up to threefold variation in prevalence was introduced by differences in the method for identifying patients with AD. Conclusions This systematic review highlights the need for clear reporting of methods for identifying patients with AD in routinely collected electronic health data to allow for meaningful interpretation and comparison of results., What's already known about this topic? Increasingly, studies are using routinely collected data to study atopic dermatitis (AD).It is unclear how patients with AD are identified and whether methodological differences could have an impact on study findings. What does this study add? We performed a systematic review of methods for identifying patients with AD in studies using routinely collected data and found differences in methods were associated with up to a threefold variation in prevalence estimates.We found variability in methods associated with up to a threefold variation in prevalence estimates.We encourage validation of methods and offer suggestions for reporting to allow for meaningful interpretation and comparison of results. https://doi.org/10.1111/bjd.16749 available online

ObjectiveThe Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing.MethodsBetween 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion.ResultsOf the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel.ConclusionsThe theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.

The aim of this study was to generate extended length, small diameter vascular scaffolds that could serve as potential grafts for treatment of acute ischemia. Biological tissues are considered excellent scaffolds, which exhibit adequate biological, mechanical, and handling properties; however, they tend to degenerate, dilate, and calcify after implantation. We hypothesized that chemically stabilized acellular arteries would be ideal scaffolds for development of vascular grafts for peripheral surgery applications. Based on promising historical data from our laboratory and others, we chose to decellularize bovine mammary and femoral arteries and test them as scaffolds for vascular grafting. Decellularization of such long structures required development of a novel “bioprocessing” system and a sequence of detergents and enzymes that generated completely acellular, galactose-(α1,3)-galactose (α-Gal) xenoantigen-free scaffolds with preserved collagen, elastin, and basement membrane components. Acellular arteries exhibited excellent mechanical properties, including burst pressure, suture holding strength, and elastic recoil. To reduce elastin degeneration, we treated the scaffolds with penta-galloyl glucose and then revitalized them in vitro using a tunic-specific cell approach. A novel atraumatic endothelialization protocol using an external stent was also developed for the long grafts and cell-seeded constructs were conditioned in a flow bioreactor. Both decellularization and revitalization are feasible but cell retention in vitro continues to pose challenges. These studies support further efforts toward clinical use of small diameter acellular arteries as vascular grafts.

Background Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures. Methods We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings Globally, life expectancy from birth increased from 61.7 years (95% uncertainty interval 61.4-61.9) in 1980 to 71.8 years (71.5-72.2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11.3 years (3.7-17.4), to 62.6 years (56.5-70.2). Total deaths increased by 4.1% (2.6-5.6) from 2005 to 2015, rising to 55.8 million (54.9 million to 56.6 million) in 2015, but age-standardised death rates fell by 17.0% (15.8-18.1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14.1% (12.6-16.0) to 39.8 million (39.2 million to 40.5 million) in 2015, whereas age-standardised rates decreased by 13.1% (11.9-14.3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42.1%, 39.1-44.6), malaria (43.1%, 34.7-51.8), neonatal preterm birth complications (29.8%, 24.8-34.9), and maternal disorders (29.1%, 19.3-37.1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death. Interpretation At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems. Copyright (C) The Author(s). Published by Elsevier Ltd.

Introduction Chronic inflammatory diseases such as eczema (also known as atopic dermatitis) have been inconsistently linked to cardiovascular disease and stroke in both mechanistic and epidemiological studies. There is a need to review the existing epidemiological data examining the association between eczema and major cardiovascular outcomes, including angina, myocardial infarction, coronary revascularisation, heart failure, cardiac arrhythmias, stroke and cardiovascular death, in order to improve our understanding of the comorbidities of eczema. Methods and analysis We will systematically review population-based studies, including cohort, case–control and cross-sectional studies, reporting on the association between eczema and cardiovascular outcomes. We will search Medline, Embase and Global Health, from their date of inception to April 2017, using a comprehensive search strategy formulated with the help of a librarian. Two reviewers will independently screen titles and abstracts in duplicate, followed by independent data extraction and quality assessment. We will group studies by the cardiovascular outcome under study and synthesise them narratively. If sufficient numbers of homogeneous studies are returned, we will perform meta-analyses to obtain pooled effect estimates. Preferred Reporting Items for Systematic Review and Meta-Analysis will be used to inform the reporting of this study. Trial registration number CRD42017060359.

Background There are sparse and conflicting data regarding the long‐term clinical course of atopic dermatitis (AD). Although often described as a childhood disease, newer population‐based estimates suggest the prevalence of pediatric and adult disease may be similar. Methods Our objective was to determine whether there is a decline in the prevalence of AD in population‐based cohorts of patients followed longitudinally beyond childhood. We conducted a systematic review and meta‐analysis including studies assessing AD prevalence across 3 or more points in time. The primary outcome was weighted overall risk difference (percentage decrease in AD prevalence). Results Of 2080 references reviewed, 7 studies with 13 515 participants were included. Participants were assessed at 3‐6 time points, ranging from age 3 months to 26 years. The percentage decrease in prevalence after age 12 was 1%, which was not significantly different from zero (95% confidence interval −2%‐5%). Similar results were found with other age cut‐offs. Conclusion The prevalence of AD in longitudinal birth cohort studies is similar in childhood and adolescence/early adulthood.

In vitro models are emerging tools for reducing reliance on traditional toxicity tests, especially in areas where information is sparse. For studies of fish, this is especially important for extrahepatic organs, such as the intestine, which, until recently, have been largely overlooked in favour of the liver or gill. Considering the importance of dietary uptake of contaminants, the rainbow trout (Oncorhynchus mykiss) intestine-derived cell line RTgutGC was cultured, to test its suitability as a high-throughput in vitro model. Benzo[a]pyrene (B[a]P) is an important contaminant and a model polycyclic aromatic hydrocarbon (PAH). Over 48 h exposure, a range of endpoints and xenobiotic metabolism rates were examined at three different pH levels indicative of the in vitro (pH 7.5) and in vivo mid-gut (pH 7.7) and hind-gut (pH 7.4) regions as a function of time. These endpoints included (i) cell viability: acid phosphatase (APH) and lactate dehydrogenase (LDH) assays; (ii) glucose uptake; (iii) cytochrome P450 enzyme activity: 7-ethoxyresoorufin-O-deethylase (EROD) assay; (iv) glutathione transferase (GST) activity; (v) genotoxic damage determined using the comet assay. Absence of cell viability loss, in parallel with decrease in the parent compound (B[a]P) in the medium and its subsequent increase in the cells suggested active sequestration, biotransformation, and removal of this representative PAH. With respect to genotoxic response, significant differences were observed at both the sampling times and the two highest concentrations of B[a]P. No significant differences were observed for the different pH conditions. Overall, this in vitro xenobiotic metabolism system appears to be a robust model, providing a basis for further development to evaluate metabolic and toxicological potential of contaminants without use of animals.

Although psoriasis has been associated with obesity, there are few prospective studies with objective measures. We prospectively examined the effect of body mass index, waist circumference, waist-hip ratio, and 10-year weight change on the risk of developing psoriasis among 33,734 people in the population-based Nord-Trøndelag Health Study (i.e., HUNT), Norway. During follow-up, 369 incident psoriasis cases occurred. Relative risk (RR) of psoriasis was estimated by Cox regression. One standard deviation higher body mass index, waist circumference, and waist-hip ratio gave RRs of 1.22 (95% confidence interval [CI] = 1.11-1.34), 1.26 (95% CI = 1.15-1.39), and 1.18 (95% CI = 1.07-1.31), respectively. Compared with normal weight participants, obese people had an RR of 1.87 (95% CI = 1.38-2.52), whereas comparing the fourth with the first quartile of waist circumference gave an RR of 1.95 (95% CI = 1.46-2.61). One standard deviation higher weight change gave an RR of 1.20 (95% CI = 1.07-1.35), and people who increased their body weight by 10 kg or more had an RR of 1.72 (95% CI = 1.15-2.58) compared with being weight stable. In conclusion, obesity and high abdominal fat mass doubles the risk of psoriasis, and long-term weight gain substantially increases psoriasis risk. Preventing weight gain and promoting maintenance of a normal body weight could reduce incidence of psoriasis.

Disability secondary to skin conditions is substantial worldwide. The Global Burden of Disease Study 2013 includes estimates of global morbidity and mortality due to skin diseases.To measure the burden of skin diseases worldwide.For nonfatal estimates, data were found by literature search using PubMed and Google Scholar in English and Spanish for years 1980 through 2013 and by accessing administrative data on hospital inpatient and outpatient episodes. Data for fatal estimates were based on vital registration and verbal autopsy data.Skin disease data were extracted from more than 4000 sources including systematic reviews, surveys, population-based disease registries, hospital inpatient data, outpatient data, cohort studies, and autopsy data. Data metrics included incidence, prevalence, remission, duration, severity, deaths, and mortality risk.Data were extracted by age, time period, case definitions, and other study characteristics. Data points were modeled with Bayesian meta-regression to generate estimates of morbidity and mortality metrics for skin diseases. All estimates were made with 95% uncertainty intervals.Disability-adjusted life years (DALYs), years lived with disability, and years of life lost from 15 skin conditions in 188 countries.Skin conditions contributed 1.79% to the global burden of disease measured in DALYs from 306 diseases and injuries in 2013. Individual skin diseases varied in size from 0.38% of total burden for dermatitis (atopic, contact, and seborrheic dermatitis), 0.29% for acne vulgaris, 0.19% for psoriasis, 0.19% for urticaria, 0.16% for viral skin diseases, 0.15% for fungal skin diseases, 0.07% for scabies, 0.06% for malignant skin melanoma, 0.05% for pyoderma, 0.04% for cellulitis, 0.03% for keratinocyte carcinoma, 0.03% for decubitus ulcer, and 0.01% for alopecia areata. All other skin and subcutaneous diseases composed 0.12% of total DALYs.Skin and subcutaneous diseases were the 18th leading cause of global DALYs in Global Burden of Disease 2013. Excluding mortality, skin diseases were the fourth leading cause of disability worldwide.

There is an increasing requirement in higher education (HE) worldwide to deliver excellence. Benchmarking is widely used for this purpose, but methodological approaches to the creation of benchmark metrics vary greatly. Approaches require selection of factors for inclusion and subsequent calculation of benchmarks for comparison. We describe an approach using machine learning to select input factors based on their value to predict completion rates of nursing courses. Data from over 36,000 students, from nine institutions over three years were included and weighted averages provided a dynamic baseline for year on year and within year comparisons between institutions. Anonymised outcomes highlight the variation in benchmarked performances between institutions and we demonstrate the value of accompanying sensitivity analyses. Our methods are appropriate worldwide, for many forms of data and at multiple scales of enquiry. We discuss our results in the context of HE management, highlighting the value of scrutinising benchmark calculations.

Background: Some malignancies are known to be associated with increased risk of herpes zoster, but little is known about how associations between cancer and subsequent zoster risk vary by cancer site, by time since cancer diagnosis, and by age. Methods: An age-, sex-, calendar time-, and practice-matched case–control study, nested in the broadly UK representative Clinical Practice Research Datalink (CPRD) primary care database, was analysed using conditional logistic regression to estimate the association between 21 of the most common specific malignancies and subsequent zoster risk. We adjusted for comorbid conditions and other potential confounders, and investigated effect modification by age and time since malignancy diagnosis. Results: A total of 192 081 adult zoster patients and 732 035 controls were included. Malignancy overall was positively associated with zoster risk (adjusted OR 1.29, 95% CI 1.27–1.32), and the association was especially strong for haematological malignancies (OR 2.46, 2.33–2.60). Among specific malignancies, there was evidence that oral, oesophageal, stomach, colorectal, lung, breast, ovarian, prostate, kidney, bladder, and CNS cancers, as well as lymphoma, myeloma, and leukaemia were associated with increased zoster odds (P⩽0.05 in each case), but the magnitude of associations varied widely. The association was typically strongest within 2 years of malignancy diagnosis and decreased with older age for both haematological and solid malignancies. Conclusions: Several cancers were associated with an increased risk of zoster, particularly within the first 2 years after diagnosis and among younger individuals. Knowledge that patients with a recent diagnosis of cancer are at high risk of zoster may encourage initiation of antiviral therapy earlier in the course of zoster when the benefits are greater. Evaluation of whether patients diagnosed with cancer would benefit from early zoster vaccination is warranted.

Background Because atopic dermatitis (AD) is a relapsing remitting disease, assessing long-term control is important. Well-controlled weeks (WCWs) have been used to assess asthma long-term control but have never been validated for AD. Objectives We sought to assess the feasibility, validity, and interpretability of WCWs in patients with AD. Methods Three studies of patients with moderate-to-severe AD, including 4 to 6 months of daily/weekly symptom and treatment use data, were evaluated (study A, n = 336; study B, n = 60; and study C, n = 224). WCWs were defined by worsening symptoms and increased medication use. Feasibility, construct validity, and interpretability of WCWs were determined by assessing missing data, association with validated AD outcomes, and floor and ceiling effects. Analysis used linear and logistic regression. Results WCWs were feasible to collect: 95.2% (study A) and 94.7% (study B) contributed data for at least half of the weekly data points, and 93.2% and 88.7% contributed to all data points up to 4 months. WCWs were significantly associated with validated AD severity instruments, including patient-orientated outcome measures and objective signs (Eczema Area and Severity Index, Three Item Severity Score, and Six Signs, Six Areas Atopic Dermatitis Scale). The odds of experiencing a WCW if AD severity was clear/mild was 5.8 (95% CI, 3.5-9.7), 1.9 (95% CI, 0.8-4.4), and 8.1 (95% CI, 4.5-14.6) in studies A, B, and C, respectively. WCWs were associated with ceiling effects: 31.6% (study A) and 37.5% (study B) of participants had no WCWs more than 90% of the time. Conclusions WCWs are valid and feasible for measuring long-term control in AD trials. However, ceiling effects and burden of data collection can limit use.

A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of acute or urgent care surgery services and "surgical hospitalist" programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.

Across amniotes, sex-determining mechanisms exhibit great variation, yet the genes that govern sexual differentiation are largely conserved. Studies of evolution of sex-determining and sex-differentiating genes require an exhaustive characterization of functions of those genes such as FOXL2 and FGF9. FOXL2 is associated with ovarian development, and FGF9 is known to play a role in testicular organogenesis in mammals and other amniotes. As a step toward characterization of the evolutionary history of sexual development, we measured expression of FOXL2 and FGF9 across 3 developmental stages and 8 juvenile tissue types in male and female American alligators, Alligator mississippiensis. We report surprisingly high expression of FOXL2 before the stage of embryonic development when sex is determined in response to temperature, and sustained and variable expression of FGF9 in juvenile male, but not female tissue types. Novel characterization of gene expression in reptiles with temperature-dependent sex determination such as American alligators may inform the evolution of sex-determining and sex-differentiating gene networks, as they suggest alternative functions from which the genes may have been exapted. Future functional profiling of sex-differentiating genes should similarly follow other genes and other species to enable a broad comparison across sex-determining mechanisms.

Acute compartment syndrome of the foot and ankle is a relatively rare clinical finding. Lower extremity compartment syndrome is customarily due to vascular or orthopedic traumatic limb-threatening pathologic issues. Clinical correlation and measurement of intracompartmental pressure are paramount to efficient diagnosis and treatment. Delayed treatment can lead to local and systemically adverse consequences. Frostbite, a comparatively more common pathologic entity of the distal extremities, occurs when tissues are exposed to freezing temperatures. Previously found in military populations, frostbite has become increasingly prevalent in the general population, leading to more clinical presentations to foot and ankle specialists. We present a review of the published data of acute foot compartment syndrome and pedal frostbite, with pathogenesis, treatment, and subsequent sequelae. A case report illustrating 1 example of bilateral foot, atraumatic compartment syndrome, is highlighted in the present report. The patient presented with changes consistent with distal bilateral forefoot frostbite, along with gangrenous changes to the distal tuft of each hallux. At admission and evaluation, the patient had increasing rhabdomyolysis with no other clear etiology. Compartment pressures were measured in the emergency room and were >100 mm Hg in the medial compartment and 50 mm Hg dorsally. The patient was taken to the operating room urgently for bilateral pedal compartment release. Both pathologic entities have detrimental outcomes if not treated in a timely and appropriate manner, with amputation rates increasing with increasing delay.

Summary Background Statins are commonly prescribed worldwide and recent evidence suggests that they may increase the risk of herpes zoster (HZ). Objectives To quantify the effect of statin exposure on the risk of HZ in the U.K. Methods A matched case–control study was conducted using data from U.K. primary care and hospital records. Patients > 18 years with an incident diagnosis of HZ were matched to up to four controls for age, sex and general practice. Patients were included in the statin exposure group if they had ever used a statin, and the daily dosage of the most recent statin prescription and the time since the most recent statin prescription were also recorded. The primary outcome was an incident diagnosis of HZ. Odds ratios (ORs) were estimated from conditional logistic regression and adjusted for potential confounders. Results A total of 144 959 incident cases of HZ were matched to 549 336 controls. Adjusted analysis suggested strong evidence for an increase in the risk of HZ related to statin exposure (OR 1·13, 95% confidence interval 1·11–1·15). There was also an increased risk when dosages were increased for patients who were currently or had recently been receiving statin treatment (P trend < 0·001), and we found an attenuation of the increased risk of HZ in previous statin users as the time since last statin exposure increased (P trend < 0·001). Conclusions These findings are consistent with the hypothesis that statin therapy leads to an increase in the risk of HZ., What's already known about this topic? Studies in both Canada and Taiwan have recently reported a small but significantly increased risk of herpes zoster (HZ) in patients receiving statin treatment.As statins are one of the most widely prescribed drugs in the U.K., with around 45 million prescriptions every year, any adverse effects will have substantial public health implications. What does this study add? In this large matched case–control study, statin exposure was associated with a modest increase in the risk of HZ.A dose–response relationship was observed, and there was an attenuation of the increased risk over time among people who stopped statin therapy, indicating that the increased risk is consistent with a causal effect.There may be extra motivation to maximize HZ vaccine uptake among eligible patients receiving a statin. Linked Comment: Shalom and Cohen. Br J Dermatol 2016; 175:1137–1138.

Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being recognized as a systemic inflammatory disorder. Psoriatic arthritis is a well-known comorbidity of psoriasis. A rapidly expanding body of literature in various populations and settings supports additional associations between psoriasis and cardiometabolic diseases, gastrointestinal diseases, kidney disease, malignancy, infection, and mood disorders. The pathogenesis of comorbid disease in patients with psoriasis remains unknown; however, shared inflammatory pathways, cellular mediators, genetic susceptibility, and common risk factors are hypothesized to be contributing elements. As additional psoriasis comorbidities continue to emerge, education of health care providers is essential to ensuring comprehensive medical care for patients with psoriasis.

Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence ( n=25) or absence ( n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3–11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.

We present two cases of ascending aortic pseudoaneurysm exclusion with off-the-shelf aortic stent grafts. The right common carotid artery was used for access to facilitate graft delivery. Control of graft deployment was aided using a compliant right atrial occlusion balloon to lower cardiac output at the time of deployment. Transesophageal echocardiography facilitated the sizing and positioning of the right atrial balloon and was used to survey the heart and ascending aorta on successful exclusion of the pseudoaneurysm. These simple maneuvers made an uncommon procedure straight forward, predictable, and successful.

Il etait suggere que les modifications phenotypiques des cellules musculaires lisses (CMLs) d’un phenotype contractile a un phenotype synthetique apres stenting endovasculaire constituaient l’origine principale des restenoses. Bien qu’il etait montre que la geometrie modifiait la reponse des CMLs a differents polymeres, l’effet de la geometrie sur le phenotype des CMLs n’etait pas bien etudie pour les materiaux utilises dans les stents endovasculaires. C’est pourquoi l’objectif de l’etude actuelle etait d’evaluer le phenotype des CMLs, leur morphologie, leur proliferation, et l’expression du marqueur contractile qu’est l’α-actine musculaire lisse, en fonction de la geometrie de l’acier 316L. Les resultats de notre etude montraient que les cellules qui croissaient sur surface micro-rainuree (profondeur de rainure: 13 μm) etaient significativement plus allongees que celles evoluant sur une surface electropolie. Apres verification par plusieurs etudes de proliferation, il apparaissait que la croissance cellulaire sur surface micro-rainuree demontrait un taux de proliferation significativement inferieur a une surface electropolie. Une meilleure expression de l’α-actine musculaire lisse etait egalement retrouvee sur surface micro-rainuree proche de la confluence. De plus, les cellules evoluant sur surface electropolie demontraient une perte substantielle de l’α-actine musculaire lisse entre les 1er et 4eme jours. Donc, etant donne la reponse favorable des CMLs rapportee dans cette etude, nos resultats suggerent qu’une geometrie micro-rainuree des stents endovasculaires pourrait avoir des effets benefiques lors de leur utilisation.

It has been hypothesized that severe psoriasis is an independent risk factor for cardiovascular disease (CVD). We prospectively studied patients with severe psoriasis treated with psoralens and ultraviolet-A therapy (PUVA) who enrolled in a cohort study in 1975-1976. From 1977 to 2005, 617 of the 1,376 patients (45%) died. Compared with the general population, cohort death rates were significantly higher than expected (standard mortality ratio (SMR) = 1.1, 95% confidence interval (CI) = 1.02-1.20). The number of deaths due to CVD (SMR = 1.02, 95% CI = 0.9-1.6) was nearly identical to the expected number. Deaths due to liver disease were significantly elevated (SMR = 4.04, 95% CI = 2.76-5.70). Patients with exceptionally severe psoriasis at entry (42% body surface area (BSA)) had a significantly increased risk of death compared with less severely affected cohort members (all-cause hazard ratio (HR) = 1.42, 95% CI = 1.18-1.69) as well as for deaths because of causes other than cancer or CVD (multivariate HR 1.56, 95% CI = 1.14-2.13). Only patients with exceptionally severe psoriasis had an increased mortality risk compared with both the general population and other cohort members with less extensive but still severe psoriasis. These increases were not significant for CVD. Our data do not support the hypothesis that severe psoriasis is an independent risk factor for CVD. However, exceptionally severe psoriasis is associated with increased all-cause mortality.

Kinchloe Roberts et al. (2008) proposed a technique, using outline-morphometric and linear analyses to permit identification of spider compression fossils to family level. This work focussed on fossil spiders from the Florissant Formation, Colorado, but the aim was to investigate a technique that would be broadly applicable to any compression fossil deposit. Essentially, what they were trying to accomplish was a shortcut for use in identifying fossil spiders to family. While their claims are promising, the methodology they used was not without its limitations and the aim of our paper is to discuss these and add further insights in order to put the application of this technique into a more appropriate context than that originally claimed.

Introduction La plupart des patients atteints d’ischemie critique (IC) ont une maladie arterielle peripherique touchant plusieurs etages (MAP-P). Un tiers des patients en IC ont une pathologie occlusive jambiere isolee (POJI). Les traitements de la MAP-P et de la POJI different sur l’utilisation de procedures ouvertes ou endovasculaires. Cependant, nous nous demandions si les resultats de ces procedures etaient egalement differents. Nous evaluions les resultats des revascularisations ouvertes et/ou endovasculaires des patients en IC et determinions l’impact de l’etendue de la maladie sur les resultats. Methodes Quatre cent quarante six patients en IC (Rutherford 4-6) revascularises entre 2001 et 2005 etaient evalues par arteriographie puis suivis par imagerie non invasive. Tous les patients ayant une POJI (occlusion d’une ou plusieurs arteres jambieres) a l’arteriographie etaient compares aux patients ayant une maladie occlusive femoro-poplitee avec ou sans maladie jambiere concomitante (MAP-P). Les patients ne presentant qu’une maladie sus-inguinale etaient exclus. Les resultats cliniques (survie, survie sans amputation, permeabilite primaire, permeabilite secondaire, sauvetage de membre, poursuite de la deambulation, et maintien de l’autonomie) etaient retrouves a partir d’une base de donnees prospective, permettant de comparer les resultats des revascularisations en fonction de la distribution de la maladie. Resultats Dans cette etude, 36% des patients avaient une POJI et 64% avaient une MAP-P. A l’entree, les symptomes ischemiques etaient une douleur de repos (28,5%), une ulceration (42,3%), et une gangrene (29,1%). Au total, 92% des patients presentaient une maladie purement sous-inguinale, alors que 8% presentaient une maladie sus- et sous-inguinale. Les facteurs de risque incluaient le diabete (61,2%), le tabagisme (61,0%), la coronaropathie (57,9%), l’hypertension (84,3%), l’hyperlipidemie (40,4%), l’obesite (15,5%), et la broncho-pneumopathie chronique obstructive (19,3%). En comparant les groupes POJI et MAP-P, il n’existait pas de difference en termes de permeabilite primaire a 2 ans. Tous les autres facteurs etaient statistiquement differents a 3 ans, dont: la survie (50,4% vs. 62,6%; p = 0,0026, hazard ratio [HR] 0,669); la survie sans amputation (35,1% vs. 50,2%; p = 0,0062; HR 0,595); le sauvetage de membre (65,2% vs. 74,4%; p = 0,0062; HR 0,595); la poursuite de la deambulation (68,9% vs. 76,9%; p = 0,0352; HR 0,644); le maintien de l’autonomie (79,0% vs. 84,8%; p = 0,0403; HR 0,599); et la permeabilite secondaire (66,8% vs. 74,8%; p = 0,0309; HR 0,665). L’analyse multivariee revelait que la POJI n’etait pas un facteur independamment associe a la survenue de complications apres controle des facteurs de confusion, parmi lesquels la perte tissulaire et l’insuffisance renale terminale etaient les plus regulierement associes a des resultats pejoratifs. Conclusion La POJI est associee a un moins bon pronostic (survie sans amputation, sauvetage de membre, survie, poursuite de la marche, et independance) apres revascularisation pour IC en comparaison a la MAP-P, malgre une plus grande etendue de la maladie chez les patients atteints de MAP-P. Les patients atteints de POJI sont plus susceptibles de presenter des facteurs de confusion comme un diabete, une insuffisance renale, et une ischemie plus severe a l’arrivee en comparaison aux patients atteints de MAP-P. La reconnaissance d’une POJI pourrait etre utile pour identifier les patients a haut risque, mais ce facteur ne constitue pas a lui seul un facteur de risque de mauvais resultat.

Restenosis remains a common problem following balloon angioplasty, and it has been speculated that changes in the mechanical environment due to endovascular interventions are correlated with shifts in smooth muscle cell (SMC) phenotype. In order to study SMC response to forces similar to those exerted during balloon angioplasty, an in vitro concurrent shear and tensile forces simulator has been developed. After 24 hr of exposure to cyclic tension (5%) and shear (0.1-0.5 dynes/cm(2)) following simulated angioplasty injury (12% stretch), rat aortic SMCs exhibited significant synthetic behavior. These responses included increased cell proliferation, apoptosis, and cell hypertrophy compared to cells exposed to strain alone. While all SMCs exposed to dynamic stimuli (strain, strain+balloon injury, strain+balloon injury+shear) demonstrated a decrease in contractile protein expression, the injury group also exhibited significantly greater expression of the synthetic marker vimentin. These in vitro findings agree with in vivo events following balloon angioplasty and present a refined dynamic model to be implemented for better understanding of SMC activation and prevention of responses through pharmacological treatment.

La restenose reste un probleme frequent apres angioplastie par ballonnet, et on a specule le que les changements de l'environnement mecanique du aux interventions endovasculaires sont correles avec des modifications du phenotype des cellules musculaires lisses (CML). Afin d'etudier la reponse des CML a des forces semblables a celles exercees pendant l'angioplastie a ballonnet, un simulateur in vitro associant des forces de cisaillement et tensiles a ete developpe. Apres 24 heures d'exposition a une tension cyclique (5%) et a un cisaillement (0.1-0.5 dyne/cm2) simules apres lesion d'angioplastie (etirement de 12%), les CML aortiques de rat avaient un comportement synthetique marque. Ces reponses incluaient une augmentation de la proliferation cellulaire, de l'apoptose, et de l'hypertrophie des cellules comparativement aux cellules exposees a la seule contrainte. Tandis que toutes les CML exposees aux stimuli dynamiques (contrainte, contrainte+lesions de ballon, contrainte+lesions de ballon +cisaillement) montraient une diminution d'expression des proteines contractiles, le groupe lesionnel avait egalement une expression significativement accrue du marqueur synthetique vimentine. Ces resultats in vitro sont conformes aux evenements in vivo apres angioplastie de ballon et representent un modele dynamique affine a mettre en application pour une meilleure comprehension de l'activation des CML et une prevention des reponses au traitement pharmacologique.

Introduction Les modifications a long terme de la morphologie de l'aorte thoracique qui peuvent affecter les resultats a long terme des lesions aortiques traumatiques traites par endoprothese sont inconnues. Le but de cette etude etait d'examiner l'histoire naturelle du diametre aortique thoracique au cours du vieillissement. Methodes Mille angioscanners thoraciques consecutifs realises pour une pathologie aortique non thoracique chez des patients âges de 15 a 99 ans (moyenne 59.4) ont ete examines, et le diametre aortique thoracique immediatement en aval de l'artere sous-claviere gauche a ete mesure. Les facteurs susceptibles d'influencer le diametre comme l'âge, la race, le sexe, l'hypertension arterielle (HTA), le diabete, la broncho-pneumopathie chronique obstructive (BPCO), et le tabagisme, ont ete examines. Ces facteurs ont ete compares en utilisant le test t de student. Resultats Les differences de diametre moyen de l'aorte thoracique en fonction du sexe (homme = 27.1 vs femme = 26.0, p = 0.87), de la race (Caucasien = 26.6 vs non-Caucasiens = 26.3, p = 0.10), de la presence d'une HTA (oui = 25.8 vs non = 24.9, p = 0.36), d'une BPCO (oui = 26.3 vs non = 25.4, p = 0.21), d'un diabete (oui = 26.1 vs non = 25.3, p = 0.12), et d'un tabagisme (oui = 26.3 contre aucuns = 25.0, p = 0.18) n'etaient pas significatives. Cependant, les differences de diametre moyen ont augmente de maniere significative avec le temps avec l'âge. Les patients âges de moins de 40 ans avaient un diametre aortique moyen de 22.92 mm compare a 27.09 mm ( p Conclusion Le diametre de l'isthme aortique augmente sensiblement avec l'âge. Ces resultats suggerent qu'une surveillance a long terme est justifiee pour les patients chez qui une endoprothese a ete mise en place pour un traumatisme afin d'evaluer l'histoire naturelle et de depister d'eventuelles complications tardives.

Fundamento Se desconocen los cambios anatomicos a largo plazo en los pacientes con traumatismo cerrado de aorta toracica tratados con endoprotesis vasculares. El objetivo de este estudio fue examinar la historia natural del diametro aortico toracico con la progresion de la edad. Metodos Se examinaron 1.000 tomografias computarizadas toracicas, efectuadas en busca de patologia no aortica toracica en pacientes de 15-99 anos de edad (media 59,4), y se determino el diametro aortico toracico inmediatamente adyacente a la arteria subclavia izquierda. Se evaluaron los factores con una posible influencia en el diametro, incluida la edad por decada de vida, raza, sexo, antecedentes de hipertension arterial (HTA), diabetes mellitus (DM), enfermedad pulmonar obstructiva cronica (EPOC) y tabaquismo. Los factores se compararon usando la prueba t de Student. Resultados Las diferencias en los diametros medios de la aorta toracica por sexo (hombres = 27,1 frente a mujeres = 26,0, p = 0,87), raza (blancos = 26,6 frente a otras razas = 26,3, p = 0,10), presencia de HTA (si = 25,8, no = 24,9, p = 0,36), EPOC (si = 26,3 frente a no = 25,4, p = 0,21), DM (si = 26,1, frente a no = 25,3, p = 0,12) y tabaquismo (si = 26,3 frente a no = 25,0, p = 0,18) no fueron significativas. Sin embargo, las diferencias en el diametro medio aumentaron significativamente a lo largo del tiempo con la edad. En pacientes 40 anos. El diametro medio del istmo aortico mostro un aumento de alrededor de 1 cm cuando se comparo a los octogenarios con los adolescentes. Conclusion El diametro del istmo aortico aumenta sustancialmente con la edad. Estos hallazgos sugieren que, para pacientes victimas de un traumatismo portadores de endoprotesis aorticas, esta justificada una vigilancia a largo plazo para monitorizar la historia natural y evaluar las posibles complicaciones tardias.

The indications for open abdominal aortic aneurysm (AAA) repair have changed with the development of endovascular techniques. The purpose of this study is to clarify the indications and outcomes for open repair since endovascular aneurysm repair (EVAR) and to compare contemporary AAA repair with the pre-EVAR era. Patients undergoing open AAA repair were identified; the demographics, outcomes, and indications for open repair were reviewed. Outcomes were compared based on indication for open repair in the EVAR era and between the pre-EVAR and EVAR eras. Open indications in the EVAR era included: age younger than 65 years with minimal comorbidities (AGE, n = 24 [9.8%]), unfavorable anatomy (ANAT, n = 146 [59.3%]), aortoiliac occlusive disease (AIOD, n = 38 [15.4%]), and miscellaneous (OTHER, n = 38 [15.4%]). Mortality (30-day and 5-year) was affected by indication: AGE = 0 and 0 per cent, ANAT = 4.1 and 49.7 per cent, AIOD = 13.5 and 32.3 per cent, and OTHER = 5.3 and 41.8 per cent. Age, sex, race, coronary artery disease, and peripheral artery disease were similar between the pre-EVAR and EVAR eras. EVAR-era patients had more diabetes mellitus, hypertension, and hyperlipidemia and longer operative time. Mortality was not different, but complication rates were lower in the pre-EVAR era (23.7 vs 43.5%, P = 0.025). Patients undergoing open AAA repair in the EVAR era have more comorbidities, longer operative times, and more complications. Outcomes for EVAR-era patients are affected by the indication for open repair. A preference for open repair in younger patients with minimal comorbidities is justified.

El dispositivo de cierre arterial StarClose (Abbott Vascular, Redwood City, CA) utiliza un clip de nitinol extraluminal para establecer la hemostasia. El objetivo de este estudio fue determinar la seguridad y la eficacia de StarClose a partir de un registro prospectivo de arteriopatia periferica (AP). A lo largo de un periodo de 18 meses se utilizaron 500 dispositivos StarClose en 378 pacientes consecutivos con AP sintomatica tras la intervencion endovascular diagnostica y/o terapeutica. Se analizaron las caracteristicas demograficas de los pacientes junto con criterios objetivos derivados del examen con eco-Doppler, la velocidad del flujo de la arteria femoral comun y el indice tobillo-brazo (ITB) obtenidos antes y despues de la colocacion del dispositivo StarClose. Todos los pacientes ambulatorios recibieron un tratamiento preventivo con antibiotico (una dosis), heparina perioperatoria (sin reversion con protamina) y tratamiento antiagregante plaquetario. Se administro acido acetilsalicilico y clopidogrel (Plavix) a todos los pacientes sometidos a intervencion terapeutica. Trescientos setenta y ocho pacientes fueron sometidos a intervenciones por una AP aortoiliaca o infrainguinal, 99 de las cuales fueron bilaterales. De los 500 cierres de abordaje arterial realizados, en 296 casos se trato de intervenciones terapeuticas con introductores de 6 a 8F en la arteria femoral comun. Los estudios diagnosticos (n = 204 abordajes arteriales) se realizaron a traves de un introductor 5F. Se consiguio con exito tecnico la hemostasia en el 97,2%; unicamente 14 dispositivos presentaron un problema de sangrado persistente en el que fue necesario prolongar la compresion manual prolongada. La mediana de la duracion de la hospitalizacion en los pacientes ambulatorios fue de 157 min. Once de los 260 seguimientos con eco-Doppler (4,2%) presentaron un aumento del doble de la velocidad sistolica maxima, siendo asintomatico solamente uno de ellos. El seguimiento tardio mostro una reduccion del ITB > 0,10 en 42 de 360 (11,7%) cierres. Se identificaron 9 complicaciones mayores (2,0%) durante el seguimiento. El dispositivo de cierre StarClose tiene una tasa de complicaciones mayores baja, y es seguro y eficaz en pacientes con AP, aunque puede producirse una estenosis en el lugar del abordaje arterial. El dispositivo consiguio una rapida hemostasia sin necesidad de reversion de la anticoagulacion y precisa, de forma significativa, menos tiempo de reposo para la deambulacion que la compresion manual.

Outcomes after lower extremity revascularization are usually reported according to the level of peripheral arterial disease (PAD, aortoiliac or infrainguinal) or the method of treatment (open or endovascular surgery). Outcomes stratified by indication, ie, claudication or critical limb ischemia (rest pain and tissue loss), have not been well studied. The purpose of this study was to compare postoperative outcomes according to the preoperative indications.Outcomes of 2,240 consecutive limb revascularizations in 1,732 patients from January 1998 through December 2005 were stratified and examined according to preoperative indication: claudication (n=999 limbs), ischemic rest pain (n=464 limbs), or tissue loss (n=777 limbs). End points measured included primary and secondary interventional or operative patency, limb salvage, survival, amputation-free survival, maintenance of ambulation, maintenance of independence, and resolution of presenting symptoms.The proportion of medical comorbidities and the severity of disease increased significantly by cohort from claudication to rest pain to tissue loss. With a mean followup of 1,089 days (range 0 to 3,689 days), overall outcomes performance declined consistently according to indication for all end points measured at 5 years (claudication, rest pain, tissue loss, p value): secondary reconstruction patency (93%, 80%, 66%, respectively; p0.001), limb salvage (99%, 81%, 68%, respectively; p0.001), survival (78%, 46%, 30%, respectively; p0.001), amputation-free survival (78%, 42%, 25%, respectively; p0.001), maintenance of ambulation (96%, 78%, 68%, respectively; p0.001), maintenance of independence (98%, 85%, 75%, respectively; p0.001), and resolution of presenting symptoms (79%, 61%, 42%, respectively; p0.001).There is a declining spectrum of outcomes performance from claudication to rest pain to tissue loss. These findings question the accuracy of all previously published data for critical limb ischemia, for which rest pain and tissue loss are usually blended and reported as a single outcomes value.

The StarClose (Abbott Vascular, Redwood City, CA) arterial closure device utilizes an extraluminal nitinol clip to establish hemostasis. The purpose of this study was to determine the safety and efficacy of StarClose from a prospective peripheral arterial disease (PAD) registry. Over an 18-month time interval, 500 StarClose devices were used in 378 consecutive patients with symptomatic PAD after diagnostic and/or therapeutic endovascular cases. Patient demographics along with objective criteria including duplex ultrasound images, common femoral artery flow velocities, and ankle-brachial indexes (ABIs) were analyzed before and after StarClose placement. All outpatients received prophylactic antibiotic (one dose), periprocedural heparin (without protamine reversal), and antiplatelet therapy. Aspirin and clopidogrel (Plavix) was used for all patients undergoing therapeutic intervention. There were 378 patients who underwent procedures for aortoiliac or infrainguinal PAD, 99 of which were bilateral. Of the 500 arteriotomy closures, 296 were therapeutic interventions with sheath sizes of 6-8 F in the common femoral artery. The diagnostic studies (n = 204 arteriotomies) were performed with a 5F sheath. The technical success in achieving hemostasis was 97.2%; only 14 devices had a deployment problem requiring prolonged manual compression. Median length of stay was 157 min for patients done on an outpatient basis. Eleven of 260 (4.2%) on duplex follow-up had a doubling of the peak systolic velocity, only one of which was symptomatic. Late follow-up showed 42 of 360 (11.7%) with a drop in ABI >0.10. Nine major complications (2.0%) were identified in follow-up. The StarClose closure device has a low major complication rate and is safe and efficacious in patients with PAD, although stenosis at the arteriotomy site may occur. The device has achieved rapid hemostasis without need for anticoagulant reversal and requires significantly less time to ambulation than manual compression.

Le dispositif de fermeture arterielle StarClose (Abbott Vascular, Redwood City, CA, Etats-Unis) utilise un clip hemostatique extraluminal en nitinol. L'objectif de cette etude etait de determiner l'efficacite et la surete du dispositif StarClose a partir d'un registre de patients porteurs d'une arteriopathie obliterante des membres inferieurs (AOMI). Au cours d'une periode de 18 mois, 500 dispositifs StarClose ont ete mis en place chez 378 patients ayant une AOMI symptomatique apres arteriographie diagnostique ou traitement endovasculaire. Les caracteristiques demographiques des patients, les echo-doppler, les vitesses des flux Doppler au niveau des arteres femorales communes (AFC) et les index des pressions cheville-bras (IPS) ont ete analyses avant et apres mise en place du StarClose. Tous les patients ont recu une antibioprophylaxie (dose unique), une injection d'heparine pendant la procedure (sans neutralisation a la protamine), et un traitement antiaggregant plaquettaire. L'aspirine et le clopidogrel (Plavix) ont ete utilises chez tous les patients ayant eu une procedure a videe therapeutique. 378 patients ont beneficie d'une intervention pour arteriopathies aorto-iliaques ou sous-inguinales, dont 99 etaient bilaterales. Parmi les 500 fermetures d'arteriotomies, 296 etaient des interventions therapeutiques avec des tailles d'introducteurs dans l'AFC comprises entre 6 et 8 F. Les procedures diagnostiques (n = 204 arteriotomies) ont ete realisees avec un introducteur de 5F. L'hemostase a ete satisfaisante dans 97,2% des cas. Un echec de deploiement du dispositif est survenu dans 14 cas, exigeant une compression manuelle prolongee. La duree mediane de sejour en ambulatoire etait de 157 minutes. 11/ 260 (4,2%) patients ont presente un doublement du pic de vitesse systolique sur le doppler de controle, entrainant des symptomes dans un cas seulement. Le suivi a long terme a montre une baisse de l'IPS > 0,10 chez 42/ 360 (11,7%) patients. Neuf complications majeures (2,0%) sont survenues durant le suivi. Le dispositif de fermeture StarClose s'accompagne d'un taux de complications majeures peu eleve. Il est fiable et efficace chez les patients presentant une AOMI, bien qu'une stenose au niveau de l'arteriotomie puisse survenir. Le dispositif a permis de realiser une hemostase rapide sans arret des anticoagulants et a diminue de maniere significative le temps d'hospitalisation ambulatoire par rapport a la compression manuelle.

Current treatment of complex aortoiliac occlusive disease (AIOD) includes the aortobifemoral bypass or the femoral-femoral bypass. However, because of bilateral groin exposure and associated risks, there is a significant morbidity associated with these procedures. In appropriate patients with unilateral AIOD, the iliofemoral bypass graft (IFBPG) via a lower abdominal retro-peritoneal incision can be an acceptable alternative. The purpose of this study is to review the safety and efficacy as well as long-term outcomes of IFBPG in patients with unilateral AIOD. From July 1997 through June 2006, 40 patients (64.3 ± 11.2-years-old, range 41–89-years-old, 57.5% critical limb ischemia, 70% male, 95% smokers) with unilateral AIOD were treated with IFBPG. Perioperative complications and symptom resolution were measured and Kaplan-Meier life table analysis was used to analyze outcomes of primary and secondary patency, survival, limb salvage, contralateral intervention, and maintenance of ambulation and independent living status. The perioperative complication rate was 12.5 per cent (n = 5) including one patient who developed atrial-fibrillation and one who developed acute renal failure. Both patients experienced resolution of these symptoms before discharge. Other complications included one limb thrombosis and two wound infections. There were no perioperative deaths. Secondary patency was 97.5 per cent and 93.3 per cent at 1 and 5 years. Limb salvage in patients with critical limb ischemia (CLI) was 85.1 per cent and 79.1 per cent at 1 and 5 years. Limb amputation occurred due to infection (n = 2), or failed IFBPG (n = 2). Thirty-one patients (77.5%) experienced symptom resolution including 15 (88.2%) of the patients treated for claudication. Two patients (5%) required contralateral iliac intervention. Patient survival was 97.5 per cent and 64.5 per cent at 1 and 5 years. Greater than 90 per cent of patients maintained their functional independence at 5 years. IFBPG achieved excellent technical and functional outcomes, particularly in patients treated for vasculogenic claudication. This procedure is relatively safe and efficacious in a population of patients with complex unilateral AIOD and can be an acceptable alternative to the aortobifemoral bypass or fem-fem procedure.

Background It is generally accepted that failed infrainguinal bypass with prosthetic material significantly compromises arterial run off, which may limit future revascularization. It is well known that the negative consequences of early vein graft thrombosis are limited, but the effect of failed peripheral angioplasty on the distal vasculature is poorly studied. The purpose of this study was to determine whether early failure after superficial femoral artery intervention influences subsequent revascularization options. Methods Between July 1, 1998, and June 30, 2006, 276 patients underwent endovascular intervention of the superficial femoral artery. A prospective analysis of angiograms done before the intervention and after early failure (≤200 days) was performed in a blinded fashion by three attending vascular surgeons to determine the optimal distal bypass site if an operation were to be performed. Inter-rater reliability of the angiogram scores was assessed using the Fleiss generalized κ for multiple raters. Potential distal anastomotic sites were classified as above knee popliteal, below knee popliteal, tibial, or no adequate site. A consensus classification was determined for each patient (2 of 3 raters). Results Of the 276 patients who underwent endovascular intervention of the superficial femoral artery, early failure was noted in 24 limbs in 23 patients. Angiographic records were available for 21 limbs in 20 patients (60% men; mean age, 65.3 ± 11.3 years), of which 60% had critical limb ischemia, 40% had claudication, and 65% had diabetes. The distal bypass site was altered in six limbs (28.6%); four from popliteal to tibial and two from above knee to below knee popliteal. Inter-rater reliability was 0.54 (moderate/good). The procedures performed on these early failures were percutaneous transluminal angioplasty ± stent (n = 14), infrainguinal bypass (n = 5), and no treatment (n = 1). Only 0.4% (1 of 276) of patients required major limb amputation due to early failure of a superficial femoral artery intervention. Conclusions Early failure after isolated endovascular intervention of the superficial femoral artery is infrequent and alters the distal target in 30% of early-failure patients if open bypass is planned. Salvage with repeat angioplasty, if necessary, can be accomplished in most patients, and the need for limb amputation is exceedingly rare. The early failure results in this study support a more liberal application of endovascular intervention to the superficial femoral artery in patients with lower extremity ischemia, especially claudication. The repercussions of late endovascular failure as well as the effects of disease progression need further study.