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Biomedical subjects

M Lepäntalo

Publications and source records attributed to M Lepäntalo.

At least 19 recordsLinked to original sources
PubMed2003

Long-term survival and health-related quality of life of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: the outcome of ruptured abdominal aortic aneurysm (RAAA) patients is most frequently measured as operative or in-hospital mortality rate. However, survival alone is not an indicator of quality of the treatment. Assessment of quality of life (QoL) is used increasingly and is a relevant measure of outcome. OBJECTIVE: to assess long-term survival and QoL of patients undergoing repair of RAAA. DESIGN: follow-up study with cross-sectional QoL evaluation. MATERIALS AND METHODS: between 1996 and 2000, 199 of 220 patients with RAAA underwent surgery. Survivors were sent the generic the RAND 36-item Health Survey (RAND-36) self-administered questionnaire. RESULTS: total hospital mortality and operative mortality were 103 of 220 (47%) and 82 of 199 (41%). Of the 117 initial survivors, 21 were deceased at the time of the study. When compared to an age- and sex-adjusted general population, only physical functioning was significantly impaired (p=0.01) in the 82 of 93 (88%) RAAA survivors who responded. CONCLUSIONS: survivors after repair of RAAA had almost the same QoL as the norms of an age- and sex-adjusted general population, justifies an aggressive operative policy in RAAA.

Aged↗
PubMed2003

Infrapopliteal bypass reduces amputation incidence in elderly patients: a population-based study.

OBJECTIVE: To examine the association between the incidences of infrapopliteal bypass for critical limb ischaemia (CLI) and major amputation in Finns aged >or=70 years. METHODS: Patients undergoing infrapopliteal bypass or major amputation for CLI during 1997 were retrospectively analysed. The incidence of major amputation in a group of hospitals performing infrapopliteal bypass "actively" was compared to that in a group performing such surgery "passively". RESULTS: The incidence of major amputations in the active (978 bypasses per million inhabitants) and passive (57 per million) groups was 1976 and 3177 per million, respectively (p = 0.016). There was a significant (p = 0.012) inverse relationship between the incidence of the two procedures in patients aged >or=80, but not <80 years. CONCLUSIONS: These results suggest that infrapopliteal bypass is effective in reducing the requirement for major amputation in patients aged >or=80 years.

Age Factors↗
PubMed2003

Ankle brachial index measurements in critical leg ischaemia--the influence of experience on reproducibility.

BACKGROUND AND AIMS: While the use of ankle brachial indices (ABI) in the screening for peripheral arterial obstructive disease is widely accepted, the applicability of ABI in the identification of critical leg ischaemia (CLI) is far from settled. The aim was to assess inter-observer variability of ABI measurements in patients with CLI. MATERIAL AND METHODS: The study was conducted in two parts. In both parts a hand-held 9.5 MHz Doppler device was used. PART A: ABI was measured by 7 measurers with variable measurement experience in 22 limbs of patients admitted to the surgical ward because of CLI. The agreement between the measurements was assessed. PART B: Inter-observer agreement in measuring ABI was assessed between 2 trained vascular technicians measuring 33 limbs in patients with CLI on the vascular outpatient clinic. RESULTS AND CONCLUSIONS: Part A: 16% of the ABI-values differed 0.15 or more from the median and the mean coefficient of variation was 56.1. Part B: The difference between measurements did not exceed 0.14 with a mean coefficient of variation of 3.2. To obtain reproducible and quantitative measurement values the measurements have to be performed by trained personnel. Measurements performed by untrained personnel can only be regarded as qualitative.

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PubMed2002

Endovascular treatment of aortic aneurysms in Finland: the first four years' experience.

BACKGROUND AND AIMS: In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry. MATERIAL AND METHODS: A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry. RESULTS: The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm. CONCLUSIONS: According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.

Adult↗
PubMed2001

Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia.

OBJECTIVES: to evaluate the results of redo bypass surgery to the infrapopliteal artery and the value of adjuvant arteriovenous fistula (AVF) in this setting. DESIGN: retrospective study. MATERIALS: fifty-one redo reconstructions to the infrapopliteal arteries were done for critical leg ischaemia in 45 patients who have had primary infrainguinal reconstructions to the popliteal artery in 20 cases (39%), the crural arteries in 18 (35%), and the pedal arteries in 13 (25%). METHODS: a PTFE prosthesis was used in 21 cases (41%). A Miller cuff was used in 16 prosthetic grafts. Adjuvant AVF was added to three autogenous vein and 12 prosthetic grafts. RESULTS: at 2 years, the primary patency rate was 42%, the secondary patency was 43%, the limb salvage was 67%, the survival was 77%, and 53% of patients were alive with salvaged leg. The primary patency rate with a vein graft was 44% at 1 year, with prosthesis plus AVF 67%, but with prosthesis without AVF only 19%. Secondary patency rates were similar. Prosthetic graft with AVF and those without AVF achieved a 1-year leg salvage rate of 100% and 51%, respectively (p =0.01). Patients with adjuvant AVF had a worse 2-year survival rate that those without AVF (31% vs 89%) (p =0.007; RR: 8.87, CI 95%: 1.62-48.42). CONCLUSIONS: redo bypass surgery using autogenous vein graft may achieve satisfactory long-term results. The use of adjuvant AVF may improve patency of redo infrapopliteal prosthetic bypass grafts.

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PubMed2001

Blood flow in a pedal bypass combined with a free muscle flap.

OBJECTIVE: to assess the haemodynamic effect of a free muscle flap on the midterm success of a pedal bypass. DESIGN: prospective consecutive study. MATERIALS: a pedal bypass (autogenous vein graft) combined with a free muscle flap was performed in 13 patients with critical leg ischaemia. The feeding artery of the flap was anastomosed end-to-side to the bypass. METHODS: blood flow was measured in the bypass before and after transplanting the flap. Doppler was used postoperatively to assess the patency. RESULTS: the bypass and flap pedicle were patent in 11 cases six months postoperatively. Two grafts were thrombosed and the legs amputated. In the successful group the median (range) blood flow in the bypass was 50 (10-100) ml/min. It increased (p<0.05) after transplantation to 64 (20-113) ml/min, being 44 (14-97) ml/min distributed to the foot. Blood flow through the flap was 20 (6-37) ml/min. The two failing grafts had a flow of 30 and 51 ml/min before and 48 and 52 ml/min after transplantation, respectively. Blood flow through the flap was 47 ml/min and 36 ml/min, respectively. In the failure group the free flap received most of the blood supply through the bypass. CONCLUSIONS: a free muscle flap connected to an infrapopliteal bypass increases the distal outflow bed and thus decreases the outflow resistance and increases graft flow.

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PubMed2001

Transfer function index of pulse volume recordings: a new method for vein graft surveillance.

OBJECTIVE: Color flow duplex scanning is currently the best method available for vein graft surveillance. However, it puts a considerable strain on the workload of a vascular unit and requires a highly trained operator. The aim of this study was to develop and validate a new, noninvasive tool for graft surveillance. The utility of transfer function index (TFI) of pulse volume recordings is tested for this purpose. METHODS: The design of the study was a blind comparative study that involved 70 testing procedures that were performed on 58 different infrainguinal vein bypass grafts. The TFI was measured with a portable vascular laboratory multi-cuff unit. Ankle/brachial indexes were obtained with the same device. Color flow duplex scanning was used as a diagnostic standard. A graft was defined as at risk, according to duplex scanning, if a local stenosis with a V2/V1 more than 2 was found or if peak systolic velocity remained less than 45 cm/s throughout the graft. The repeatability of the method was tested on 30 grafts. RESULTS: A total of 63 tests were available for analysis. Seven tests were excluded. Four were excluded because they had unreliable TFI measurement due to cardiac arrhythmias, and in three tests, the whole graft could not be visualized in the duplex scan. Forty normal and 22 at-risk grafts were found. One graft was occluded. The TFI was significantly lower for at-risk grafts (0.89) versus normal grafts (1.09; P =.005). A TFI of 1.02 or less correctly detected 21 of 22 at-risk grafts. The sensitivity, specificity, and accuracy were 96%, 65%, and 76%, respectively. The ability of the ankle/brachial index to detect the at-risk grafts was clearly inferior to the TFI. The repeatability of the method at proximal thigh, distal thigh, and proximal calf was +/- 0.21, +/- 0.07, and +/- 0.14, respectively. CONCLUSION: The TFI is a sensitive and reliable method to detect an at-risk graft. The examination is noninvasive, simple, quick to perform, and well tolerated by the patients. We suggest that the TFI could be the first-line screening method in vein graft surveillance.

Blood Volume↗
PubMed2001

Intraoperative flow predicts the development of stenosis in infrainguinal vein grafts.

OBJECTIVE: There are data to suggest that the development of myointimal hyperplasia is affected by long-term alterations in blood flow. However, the clinical relevance of these findings has not been demonstrated. METHODS: In this retrospective clinical study, intraoperative volume flow measurement with transit time flowmeter was performed in 257 infrainguinal vein grafts carried out in 241 patients. The patients were enrolled in an intensive duplex scanning-based surveillance program. The relationship between the intraoperative graft flow and subsequent occlusion or development of stenosis was evaluated and controlled for other pertinent risk factors. RESULTS: The median follow-up time was 13.6 months. A graft stenosis was found in 58 grafts. The mean graft flow for event-free grafts was 98 mL/min, which was significantly higher compared with 78 mL/min for stenosed or 69 mL/min for occluded grafts. The patients were divided into four groups according to quartiles of the sample distribution of graft flow measurements. The respective 2-year primary and assisted primary patency rates in the lowest to the highest graft flow groups were 39%, 49%, 47%, and 72% (P =.003) and 55%, 67%, 71%, and 84% (P =.01). Analogous significant differences were observed for maximal flow capacity measurements. Female sex (P =.009) and low graft flow in maximal flow capacity measurements (P =.003) were independent predictors of stenosis development in the multiple regression model. CONCLUSION: Intraoperative graft volume flow is a predictor of bypass occlusion after infrainguinal bypass. In addition, this study verifies an association between the development of clinically evident graft stenoses and low graft flow.

Adult↗
PubMed2001

Preliminary results with endoluminal femoropopliteal thrupass.

BACKGROUND AND AIMS: Results of endovascular procedures to the superficial femoral artery and popliteal artery are not as good as at the iliac level. The purpose of this study is to evaluate the long-term results of a new endoluminal stent-graft for the management of lesions of the femoropopliteal segment. MATERIAL AND METHODS: Fifteen patients underwent endoluminal treatment of femoropopliteal lesions with a PTFE covered stent-graft. Nine patients had critical leg ischaemia, two patients had acute leg ischaemia, two patients were claudicants, one patient had a ruptured popliteal artery aneurysm, and one had a large adjuvant therapeutic arteriovenous fistula. RESULTS: The procedure was successfully carried out in all patients. Thrombosis occurred in two stent-grafts 4.5 months and 12.5 months after the procedure. One of them was successfully thrombolysed. During the two-year follow-up, a haemodynamically significant decrease in ankle/brachial index was observed in two patients. Ankle/brachial index was the same or higher than the immediately postoperative value in six patients. Primary patency rates at 1 month, 1 year and 2 year follow-up were 100%, 93% and 84%, respectively. Assisted primary patency rates at the same intervals were 100%, 93% and 93%, respectively. No patient had limb loss during the follow-up period. CONCLUSIONS: Endoluminal femoropopliteal bypass using PTFE covered stent-graft can be successfully performed with good two-year results.

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PubMed2001

Increased preoperative c-reactive protein level as a prognostic factor for postoperative amputation after femoropopliteal bypass surgery for CLI.

BACKGROUND AND AIMS: We evaluated the possible predictive role of C-reactive protein (CRP) on the immediate postoperative outcome after femoropopliteal bypass surgery for critical leg ischaemia (CLI). MATERIAL AND METHODS: 138 patients with CLI who underwent 143 femoropopliteal reconstructions. RESULTS: The immediate postoperative period secondary patency rate was 87%, leg salvage rate was 94%, and survival rate 97%. Nine patients (6.3%) had 30-day postoperative major amputation, three of them despite a patent bypass graft because of progression of foot infection. The preoperative serum concentration of CRP was the only predictor of postoperative major amputation (p = 0.004; for an increase of 10 mg/l: OR, 1.188; CI 95%, 1.059-1.332). The median preoperative serum concentration of CRP among patients who did not have major amputation was 13.0 mg/l (range, 1-185), whereas it was 47.5 mg/l (range, 5-168) among those who had amputation after bypass graft occlusion, and 115.0 mg/l (range, 34-222) among those who had amputation despite a patent bypass graft (p = 0.008). CONCLUSIONS: CRP may be a useful marker in risk stratification for postoperative amputation in patients undergoing femoropopliteal bypass surgery for CLI.

Adult↗
PubMed2001

Endovascular surgery for chronic limb ischaemia. Factors predicting immediate outcome on the basis of a nationwide vascular registry.

PURPOSE: To evaluate the early results of endovascular treatment of chronic limb ischemia and the factors influencing outcome. METHODS: The 5,575 endovascular procedures entered into the national vascular registry in 1991-1994 were reviewed retrospectively. Indication was claudication in 3,873 and chronic critical ischemia (CLI) in 1,702 procedures. In CLI most patients were women and older, with a higher proportion of diabetes mellitus, renal insufficiency and coronary heart disease than in claudication group although the incidence of smoking and hyperlipidaemia was lower. 60.2% of the procedures were performed in femoropopliteal arteries, 24.9% in iliac arteries and 14.9% in infrapopliteal arteries. The follow-up was 30 days. RESULTS: In the claudication group there was clinical improvement in 2,719 (82.8%) and in the CLI group in 851 (70.9%) of patients. Patency was better in the claudication than in CLI group, 94.6% vs. 89.0% respectively. There was hemodynamic improvement, i.e. improvement of the ankle-brachial index of more than 0.15 in 1,680 (58.2%) patients with claudication and in 437 (59.7%) with CLI. In a logistic regression model diabetes mellitus and renal insufficiency increased the relative risk of amputations and mortality in CLI group, whereas, incidence of amputations was lower in patients with hyperlipidaemia. In claudication group femoropopliteal arteries had an adverse effect on patency. CONCLUSION: The clinical characteristics of the groups may explain some of the outcome differences. Angioplasty is recommended to be used in the femoropopliteal arteries if the symptoms are severe and in CLI group with diabetes and renal failure only in selected cases.

Adult↗
PubMed2001

Claudication does not always precede critical leg ischemia.

Prevalence of intermittent claudication is often used to calculate the prevalence of critical leg ischemia (CLI), a more severe form of peripheral arterial disease (PAD). Although this logical course of the disease is intellectually appealing, not all patients with CLI have experienced any symptoms of previous claudication. A total of 100 consecutive patients with objective evidence of critical ischemia, as evaluated by non-invasive testing in the authors' vascular laboratory, were subjected to a structured interview to evaluate how often peripheral arterial disease is presented with symptoms of CLI as the initial complaint. In all, 37 patients had never experienced claudication prior to the development of CLI. Furthermore, 12 of 63 patients who suffered from previous claudication did not have any claudication symptoms at the time of the development of CLI. Of the 37 patients with CLI as the first sign of PAD, 20 had diabetes--four of whom with manifest diagnosed neuropathy. The patients without previous claudication more frequently had ulcers as the initial symptom of CLI (89%) than those with claudication (59%), whose disease first progressed to rest pain. Altogether, 25 patients did not walk enough to develop symptoms of claudication. In conclusion, every patient presenting with symptoms potentially related to CLI should undergo vascular laboratory measurements regardless of whether he/she has a history of claudication or not. This is especially true in limbs with unhealed skin lesions.

Adult↗
PubMed2000

Cost-effectiveness of Percutaneous Transluminal Angioplasty (PTA) Versus Vascular Surgery in Limb-threatening Ischaemia.

The purpose of this study was to analyze the cost and cost-effectiveness of femoropopliteal PTA compared to femoropopliteal bypass surgery in chronic critical ischaemia of the lower limb. A total of 772 patients were treated either by femoropopliteal PTA or vascular reconstruction in two of the three largest vascular centers in Finland 1991-1992. A subset of 124 cases with chronic critical leg ischaemia, which according to a retrospective independent analysis by a vascular surgeon and a radiologist could have been treated with either modality, were included in the study. Eighty-six of those were treated with PTA and 38 with surgery. The patients were followed up for to three years after treatment. Clinical outcomes were measured as change in the ABI (ankle-brachial pressure index) and avoidance of reoperation and amputation. The hospital costs covering all events from preoperative examinations to the three-year follow-up visit were identified by using hospital discharge register and accounting data. Cost-effectiveness was calculated as cost per reoperation-free year and year of leg saved. Surgery cases were found to have a more severe disease as indicated by lower distal pressures and longer occlusions and they also showed a slightly better clinical outcome, although the differences were not statistically significant. PTA costs were half of those of vascular surgery. The cost-effectiveness rates were significantly better for the PTA patients. PTA is a feasible and cost-effective procedure in chronic critical ischaemia of the lower limb and should be the treatment of choice in the subset of patients where both procedures are possible.

Journal Article↗
PubMed2000

Lower limb revascularization and free flap transfer for major ischemic tissue loss.

The objective of this study was to assess the value of lower limb revascularization and free flap transfer (LLR-FFT) in the management of critical leg ischemia and major tissue loss. A total of 29 consecutive patients with critically ischemic leg and major tissue loss underwent 24 simultaneous and 6 staged LLR-FFT procedures. The main outcome measures were bypass graft patency, free flap viability, leg salvage, patients alive with salvaged leg, and survival. At the 2-year follow-up, the bypass graft patency rate was 85%, secondary free flap viability rate was 82%, and 82% of patients achieved leg salvage and were ambulant. If the success was defined as patients being alive with a salvaged leg, the corresponding rate was 80%. Three patients achieved long-term primary patency and leg salvage despite free flap failure, which occurred during the 30-day postoperative period. Lower extremity revascularization plus free flap coverage of large ischemic lesions is valuable in achieving long-term leg salvage. Because revascularization and conventional management of major tissue loss alone can be effective in the management of a small number of cases, staged LLR-FFT is indicated, when appropriate, for better selection of patients undergoing such an aggressive and demanding treatment.

Adult↗
PubMed2000

Limits of infrapopliteal bypass surgery for critical leg ischemia: when not to reconstruct.

The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical leg ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p = 0.03), postoperative cardiac complications (p = 0.02), leg salvage (p = 0.009), amputation with patent graft (p = 0.009), and patients who survived with a salvaged leg (p = 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on leg salvage (p = 0.02) and on patients alive with salvaged leg rates (p = 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical leg ischemia, as these patients are at high risk for early postoperative leg or life loss.

Adult↗
PubMed2000

Major surgery increases serum levels of vascular endothelial growth factor only temporarily.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a hypoxia-induced endothelial cell-specific mitogen, which is angiogenic in vivo and up-regulated in several malignancies. VEGF can be used as a prognostic marker, but the effect of surgical trauma on serum VEGF (S-VEGF) concentrations is unknown and might reduce the value of VEGF as a serum marker. METHODS: We monitored S-VEGF levels by enzyme-linked immunosorbent assay in patients undergoing surgery. RESULTS: Eighteen patients with major surgery had slightly elevated S-VEGF compared with the preoperative level (median 9.5 pg/mL) on the first (median 35 pg/mL; P = 0.0002) and third (median 19 pg/mL; P = 0.004) postoperative day, but not in later samples. The levels measured in 8 patients after minor surgery did not differ from the preoperative levels (P = 0.14). CONCLUSIONS: Even major surgery is associated only with a slight and transient increase in S-VEGF levels, and, therefore, is unlikely to interfere markedly with the use of VEGF as a prognostic marker.

Endothelial Growth Factors↗