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  • 1.
    Arfvidsson, Berndt
    et al.
    Dept Cardiothorac & Vasc Surg, Örebro Univ Hosp, Örebro, Sweden.
    Nilsson, Torbjörn K.
    Dept Med Biosci Clin Chem, Umeå Univ, Umeå, Sweden.
    Norgren, Lars
    Fac Hlth Med & Care, Univ Örebro, Örebro, Sweden; Dept Surg, Örebro Univ Hosp, Orebro, Sweden.
    S100B concentrations increase perioperatively in jugular vein blood despite limited metabolic and inflammatory response to clinically uneventful carotid endarterectomy2015In: Clinical Chemistry and Laboratory Medicine, ISSN 1434-6621, E-ISSN 1437-4331, Vol. 53, no 1, p. 111-117Article in journal (Refereed)
    Abstract [en]

    Background: Our aim was to test the hypothesis that metabolic and inflammatory responses of the brain perioperatively during carotid endarterectomy (CEA) might affect blood brain barrier (BBB) integrity.

    Methods: Twenty patients with >70% stenosis of internal carotid artery (ICA) were prospectively included. Surgery was performed under general anaesthesia. Blood was sampled from ipsilateral internal jugular vein and radial artery: just before, during, and after ICA clamping S100B protein, glucose, lactate, 20 amino acids, and key cytokines were analysed.

    Results: Jugular vein S100B increased during clamping and reperfusion, while a marginal systemic increase was recorded, unrelated to stump pressure during clamping. Glucose increased during clamping in jugular vein blood and even more systemically, while jugular lactate values were higher than systemic values initially. Most amino acids did not differ significantly between jugular vein and systemic levels: glutamic acid and aspartic acid decreased during surgery while asparagine increased. Jugular vein interleukin (IL)-6 showed a transient non-significant increase during clamping and decreased systemically. IL-8 and IL-10 increased over time.

    Conclusions: Rising jugular vein S100B concentrations indicated reduced BBB integrity, and marginal secondary increase of S100B systemically. Limited ischaemic effects on the brain during cross-clamping, unrelated to S100B concentrations, were confirmed by lower brain glucose levels and higher lactate levels than in systemic blood. The lack of increased jugular vein glutamic acid disproves any major ischaemic brain injury following CEA. The inflammatory response was limited, did not differ greatly between jugular and systemic blood, and was unrelated to S100B.

  • 2. Bergqvist, David
    et al.
    Björck, Martin
    Eliason, Ken
    Forssell, Claes
    Jansson, Ingvar
    Karlström, Lars
    Lundell, Anders
    Malmstedt, Jonas
    Norgren, Lars
    Örebro University, Department of Clinical Medicine.
    Troëng, Thomas
    Inga dödsfall/slaganfall efter kirurgi vid asymtomatisk karotisstenos: femårsresultat redovisat i riksstäckande register2006In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 103, no 5, p. 301-302Article in journal (Refereed)
    Abstract [en]

    In the Swedish vascular registry 7473 carotid endarterectomies are registered, in 10% the indication being a symptomatic stenosis. There are great variations in indication for carotid endarterectomy within Sweden. During the last five years the combined postoperative mortality and/or postoperative permanent stroke has varied between 3% in 1999 and 1.5% in 2003. During the same period not a single patient operated on for a symptomatic carotid stenosis experienced these complications.

  • 3. Björck, M.
    et al.
    Bergqvist, D.
    Eliasson, K.
    Jansson, I.
    Karlström, L.
    Kragsterman, B.
    Lundell, A.
    Malmstedt, J.
    Nordanstig, J.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Troëng, T.
    Twenty years with the Swedvasc Registry2008In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 35, no 2, p. 129-130Article in journal (Refereed)
  • 4. Danielsson, P.
    et al.
    Truedsson, L.
    Norgren, Lars
    Örebro University, Department of Clinical Medicine.
    Systemic white blood and endothelial cell response after revascularization of critical limb ischemia is only influenced in case of ischemic ulcers2006In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 25, no 3, p. 310-315Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study was to study the inflammatory response to open revascularization of an ischemic leg in terms of activation of white blood cells (WBC), platelets and endothelial cells. DESIGN: prospective study. METHODS: Venous samples from 21 patients suffering critical limb ischemia (CLI) were drawn before, and 4 weeks after (20 patients) revascularization. Total WBC, differentiated WBC, and platelets were counted. Expression of CD11b/CD18 on granulocytes and monocytes and CD41 on platelets was measured by flow cytometry. Soluble endothelial markers (sICAM-1, sVCAM-1, sE-selectin and sP-selectin) were analysed with ELISA. RESULTS: WBC and granulocyte count decreased in the subgroup of patients with ulcer and gangrene but no change in activation of WBC was recorded. The endothelial marker sICAM-1 decreased while VCAM-1 increased following surgery, most evident in the subgroup with ulcers and gangrene. CONCLUSIONS: This study shows that revascularization of CLI does not significantly influence the inflammatory response in patients with rest pain only, but a limited response of down regulation was found in the ulcer/gangrene patients probably as an effect of healing ulcers.

  • 5. Dormandy, J. A.
    et al.
    Betteridge, D. J.
    Schernthaner, G.
    Pirags, V.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Impact of peripheral arterial disease in patients with diabetes: results from PROactive (PROactive 11)2009In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 202, no 1, p. 272-281Article in journal (Refereed)
    Abstract [en]

    We compared cardiovascular disease outcomes according to the presence of peripheral arterial disease (PAD) at baseline in a post hoc analysis from the PROactive study. Of the 5238 patients in PROactive (a study of pioglitazone versus placebo in patients with type 2 diabetes and macrovascular disease; mean follow-up=34.5 months), 1274 had PAD at baseline (619=pioglitazone; 655=placebo). Patients with PAD at baseline showed significantly higher rates of the primary endpoint, main secondary endpoint, all-cause mortality (all P<0.0001), and stroke (P=0.0175) than those with no PAD at baseline. The risk of PAD alone was similar to that of myocardial infarction alone. In patients with no PAD at baseline, the event rates of the primary endpoint (P=0.0160), main secondary endpoint (P=0.0453), and acute coronary syndrome (P=0.0287) were significantly lower with pioglitazone than with placebo. This beneficial effect of pioglitazone was not seen in patients with PAD at baseline. In the total population, there was a higher frequency of leg revascularizations with pioglitazone than placebo-this was wholly due to first events that occurred within the initial 12 months of treatment. The presence of PAD increased the risk of all major cardiovascular events. Those without PAD at baseline seemed to benefit more from pioglitazone treatment than the overall PROactive population.

  • 6.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Jansson, Kjell
    Region Örebro län, Örebro, Sweden.
    Complications but not obesity or diabetes mellitus have impact on the intraperitoneal lactate/pyruvate ratio measured by microdialysis2010In: Scandinavian Journal of Gastroenterology, ISSN 1502-7708, Vol. 45, no 1, p. 115-121Article in journal (Refereed)
    Abstract [en]

    Objective: Studies have shown a higher risk of postoperative complications in diabetic and obese patients. An increased intraperitoneal lactate/pyruvate ratio as measured by microdialysis has been reported before postoperative complications have been discovered. It is not known whether diabetes or obesity have any influence on the intraperitoneal metabolism (lactate/pyruvate ratio, glucose, glycerol) in relation to major abdominal surgery. The aim of this study was to investigate the postoperative intraperitoneal and subcutaneous carbohydrate and fat metabolism as measured by microdialysis in obese and diabetic patients after major abdominal surgery without postoperative complications.

    Material and methods: Seven obese patients (body mass index > 30 kg/m(2)) and six diabetic but non-obese patients were studied up to 48 h after major abdominal surgery and were compared with 31 non-diabetic, non-obese patients, all without complications. Microdialysis was performed to measure glucose, lactate, pyruvate and glycerol intraperitoneally and subcutaneously. The lactate/pyruvate ratio was calculated.

    Results: The lactate/pyruvate ratio did not differ between the groups. In the diabetic patients, glucose levels were higher intraperitoneally at both Days 1 and 2 compared to controls. Higher glycerol levels were found subcutaneously in obese patients at Day 2. CONCLUSIONS: The lactate/pyruvate ratio does not increase intraperitoneally after non-complicated major abdominal surgery in diabetic and obese patients. Obese patients have increased release of free fatty acids and glycerol subcutaneously, while diabetic patients show higher glucose levels intraperitoneally than controls.

  • 7.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Sweden.
    Skoog, Per
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Sweden.
    Nilsson, Kristofer F.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University and Örebro University Hospital, Sweden.
    Oikinomakis, Ioannis
    Department of Surgery Örebro University and Örebro University Hospital, Sweden.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University and Örebro University Hospital, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences. Department of Surgery Örebro University and Örebro University Hospital, Sweden.
    Jansson, Kjell
    Department of Surgery Örebro University and Örebro University Hospital, Sweden.
    Intraperitoneal metabolic consequences of supra-celiac aortic balloon occlusion versus superior mesenteric artery occlusion: an experimental animal study utilising microdialysisManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To investigate the effect of aortic supra-celiac balloon occlusion (ABO) and superior mesenteric artery (SMA) occlusion on abdominal visceral metabolism in an animal model by using intraperitoneal microdialysis (IPM) and laser Doppler flowmetry. Design: Prospective study in pigs

    Material and methods: Nine pigs were subjected to ABO and seven animals were subjected to SMA occlusion for one hour followed by three hours of reperfusion. Seven animals served as controls. Hemodynamic data, arterial blood samples, urinary output and intestinal mucosal blood flow (IBF) were followed hourly. Intraperitoneal (i.p) glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured by IPM.

    Results: Compared to baseline, ABO reduced IBF by 76% and decreased urinary output. SMA occlusion reduced IBF by 75% without affecting urinary output. ABO increased the i.p l/p ratio from 18 at baseline, peaking at 46 in early reperfusion. SMA occlusion and reperfusion tended to increase the i.p l/p ratio, peaking at 36 in early reperfusion. ABO increased the i.p glycerol concentration from 87 μM at baseline to 579 μM after three hours of reperfusion. SMA occlusion and reperfusion increased the i.p glycerol concentration but to a lesser degree.

    Conclusions: Supra-celiac ABO caused severe hemodynamic, renal and systemic metabolic disturbances compared to SMA occlusion, most likely due to the more extensive ischemiareperfusion injury. The intra-abdominal metabolism, measured by microdialysis, was affected both by ABO and SMA occlusion but the most severe disturbances were caused by ABO. The i.p l/p ratios and the glycerol concentrations increased during ischemia and reperfusion and may serve as markers of these events and indicate anaerobic metabolism and cell damage respectively.

  • 8.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Skoog, Per
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Oikonomakis, Ioannis
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Intraperitoneal Metabolic Consequences of Supraceliac Aortic Balloon Occlusion in an Experimental Animal Study Using Microdialysis2014In: Annals of Vascular Surgery, ISSN 0890-5096, E-ISSN 1615-5947, Vol. 28, no 5, p. 1286-1295Article in journal (Refereed)
    Abstract [en]

    Background: To investigate the effects of supraceliac aortic balloon occlusion (ABO) and superior mesenteric artery (SMA) occlusion on abdominal visceral metabolism in an animal model using intraperitoneal microdialysis (IPM) and laser Doppler flowmetry.

    Methods: A total of 9 pigs were subjected to ABO and 7 animals were subjected to SMA occlusion for 1 hour followed by 3 hours of reperfusion. Seven animals served as controls. Hemodynamic data, arterial blood samples, urinary output, and intestinal mucosal blood flow (IBF) were followed hourly. Intraperitoneal (i.p) glucose, glycerol, lactate, and pyruvate concentrations and lactate-to-pyruvate (lip) ratio were measured using IPM.

    Results: Compared with the baseline, ABO reduced IBF by 76% and decreased urinary output. SMA occlusion reduced IBF by 75% without affecting urinary output. ABO increased the i.p lip ratio from 18 at baseline, peaking at 46 in early reperfusion. SMA occlusion and reperfusion tended to increase the i.p lip ratio, peaking at 36 in early reperfusion. ABO increased the i.p glycerol concentration from 87 mu M at baseline to 579 p,M after 3 hours of reperfusion. SMA occlusion and reperfusion increased The i.p glycerol concentration but to a lesser degree.

    Conclusions: Supraceliac ABO caused severe hemodynamic, renal, and systemic metabolic disturbances compared with SMA occlusion, most likely because of the more extensive ischemia-reperfusion injury. The intra-abdominal metabolism, measured by microdialysis, was affected by both ABO and SMA occlusion but the most severe disturbances were caused by ABO. The i.p lip ratios and the glycerol concentrations increased during ischemia and reperfusion and may serve as markers of these events and indicate anaerobic metabolism and cell damages respectively.

  • 9.
    Hörer, Tal
    et al.
    Örebro University Hospital. School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Skoog, Per
    Örebro University Hospital, Örebro, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Norgren, Lars
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Örebro University Hospital, Örebro, Sweden.
    Magnuson, A.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Berggren, Lars
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Örebro University Hospital, Örebro, Sweden.
    Jansson, Karl
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Örebro University Hospital, Örebro, Sweden.
    Intra-peritoneal microdialysis and intra-abdominal pressure after endovascular repair of ruptured aortic aneurysms2013In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, p. 596-606Article in journal (Refereed)
    Abstract [en]

    Objectives: This study aims to evaluate intra-peritoneal (ip) microdialysis after endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) in patients developing intra-abdominal hypertension (IAH), requiring abdominal decompression.

    Design: Prospective study.

    Material and methods: A total of 16 patients with rAAA treated with an emergency EVAR were followed up hourly for intra-abdominal pressure (IAP), urine production and ip lactate, pyruvate, glycerol and glucose by microdialysis, analysed only at the end of the study. Abdominal decompression was performed on clinical criteria, and decompressed (D) and non-decompressed (ND) patients were compared.

    Results: The ip lactate/pyruvate (l/p) ratio was higher in the D group than in the ND group during the first five postoperative hours (mean 20 vs. 12), p = 0.005 and at 1 h prior to decompression compared to the fifth hour in the ND group (24 vs. 13), p = 0.016. Glycerol levels were higher in the D group during the first postoperative hours (mean 274.6 vs. 121.7 mu M), p = 0.022. The IAP was higher only at 1 h prior to decompression in the D group compared to the ND group at the fifth hour (mean 19 vs. 14 mmHg).

    Conclusions: lp l/p ratio and glycerol levels are elevated immediately postoperatively in patients developing IAH leading to organ failure and subsequent abdominal decompression.

  • 10.
    Jonsson, Thomas B.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Department of Surgery, University Hospital, Örebro, Sweden.
    Arfvidsson, B.
    Department of Surgery, University Hospital, Örebro, Sweden.
    Tidefelt, Ulf
    Örebro University, School of Medicine, Örebro University, Sweden. Department of Medicine, University Hospital, Örebro, Sweden.
    Axelsson, C.-G.
    Department of Transfusion Medicine, University Hospital, Örebro, Sweden.
    Jurstrand, M.
    Clinical Research Centre, University Hospital, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Surgery, University Hospital, Örebro, Sweden.
    Adverse events during treatment limb ischemia with autologous peripheral blood mononuclear cell implant2012In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 31, no 1, p. 77-84Article in journal (Refereed)
    Abstract [en]

    Aim: Trials have reported clinical improvement and reduced need for amputation in critical limb ischemia (CLI) patients receiving therapeutic angiogenesis with stem cells. Our objective was to test peripheral stem cell therapy efficacy and safety to gain experiences for further work.

    Methods: We included nine CLI patients (mean age 76.7 ±9.7). Stem cells were mobilized to the peripheral blood by administration of G-CSF (Filgrastim) for 4 days, and were collected on day five, when 30 mL of a stem cell suspension was injected into 40 points of the limb. The clinical efficacy was evaluated by assessing pain relief, wound healing and changes in ankle-brachial pressure index (ABI). Local metabolic and inflammatory changes were measured with microdialysis, growth factors and cytokine level determination. Patients were followed for 24 weeks.

    Results: Four patients experienced some degree of improvement with pain relief and/or improved wound healing and ABI increase. One patient was lost to follow up due to chronic psychiatric illness; one was amputated after two weeks. Two patients had a myocardial infarction (MI), one died. One patient died from a massive mesenteric thrombosis after two weeks and one died from heart failure at week 11. Improved patients showed variable effects in cytokine-, growth factor- and local metabolic response.

    Conclusion: Even with some improvement in four patients, severe complications in four out of nine patients, and two in relation to the bone marrow stimulation, made us terminate the study prematurely. We conclude that with the increased risk and the reduced potential of the treatment, peripheral blood stem cell treatment in the older age group is less appropriate. Metabolic and inflammatory response may be of value to gain insight into mechanisms and possibly to evaluate effects of therapeutic angiogenesis.

  • 11.
    Jonsson, Thomas Björn
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Nilsson, T. K.
    Dept Med Biosci Clin Chem, Umeå Univ, Umeå, Sweden.
    Breimer, Lars H.
    Örebro University Hospital. Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Schneede, J.
    Dept Clin Pharmacol, Umeå Univ, Umeå, Sweden.
    Arfvidsson, B.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences. Department of Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Cloxacillin concentrations in serum, subcutaneous fat, and muscle in patients with chronic critical limb ischemia2014In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 70, no 8, p. 957-963Article in journal (Refereed)
    Abstract [en]

    Patients suffering from critical limb ischemia (CLI) have poor wound healing in the ankle and foot areas. Secondary wound infections are frequent and often treated with prolonged courses of antibiotics.

    This study set out to investigate to what extent the unbound fraction of 4 g of cloxacillin i.v. reaches its target organ in poorly vascularized tissues, i.e., the calf and foot of patients suffering from CLI.

    Cloxacillin concentrations were measured by HPLC in serum and in microdialysis samples from skin and muscle of the lower part of the calf and as reference subcutaneously at the pectoral level in eight patients suffering from CLI (four males, four females, mean age 78 years, range 66-85 years) and in three healthy controls (two females, one male, mean age 67, range 66-68 years).

    In patients suffering from CLI, the tissue penetration of cloxacillin after a single 4 g dose was comparable to that of healthy controls, despite impaired blood circulation.

    The reduced blood flow in the peripheral vessels of the CLI patients presented here apparently is not the rate-limiting factor for delivery or tissue penetration of cloxacillin.

  • 12. Jonsson, Thomas
    et al.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences.
    Jansson, Kjell
    Arfvidsson, Berndt
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Limb ischemia after EVAR: an effect of the obstructing introducer?2008In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 15, no 6, p. 695-701Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate the splanchnic and limb metabolic effects of open repair (OR) of abdominal aortic aneurysms (AAA) versus endovascular aneurysm repair (EVAR) in a pilot study utilizing microdialysis. METHODS: Nine AAA patients (8 men; mean age 74 years, range 61-85) were treated with EVAR and 9 had an OR (5 men; mean age 70 years, range 55-85). In the EVAR cases, which were performed percutaneously, the external iliac artery was obstructed by the introducer to a mean functional stenosis of 70% (52%-100%). Catheters for microdialysis were placed subcutaneously above the ankle of the right leg and freely in the abdominal cavity to measure the levels of lactate and pyruvate. The lactate/pyruvate ratio was calculated as a measure of ischemia. Measurements started at the end of surgery and continued for 2 days. Mean values were compared using the Mann-Whitney U test. RESULTS: The mean value of intraperitoneal lactate during the first day after EVAR was 1.5+/-0.7 mM versus 2.6+/-0.8 mM after OR (p = 0.019). The lactate/pyruvate ratio was 10.2+/-2.2 after EVAR and 12.3+/-2.6 after OR (p = 0.113). Leg lactate mean values were 4.2+/-2.0 mM after EVAR versus 1.8+/-0.6 mM after OR (p<0.001). The lactate/pyruvate ratio was 20.1+/-8.3 for EVAR and 13.7+/-3.3 for OR (p = 0.040). These differences between EVAR and OR continued for the second day. CONCLUSION: Intraperitoneally, metabolism was slightly increased after OR; however, it was not suggestive of splanchnic ischemia. Leg findings reflected a more extensive ischemia after EVAR over 48 hours, which was a somewhat unexpected finding that may be related to the introducer's impact on blood flow to the limb during the intervention. Although no clinical consequences were recorded, the finding suggests some benefit of minimizing as much as possible the time of reduced perfusion to the limb.

  • 13. Liapis, C. D.
    et al.
    Bell, P. R. F.
    Mikhailidis, D.
    Sivenius, J.
    Nicolaides, A.
    Fernandes e Fernandes, J.
    Biasi, G.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    ESVS guidelines: Invasive treatment for carotid stenosis: indications, techniques2009In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 37, no 4, Suppl 1, p. S1-S19Article in journal (Refereed)
    Abstract [en]

    The European Society for Vascular Surgery brought together a group of experts in the field of carotid artery disease to produce updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence. Carotid endarterectomy (CEA) is recommended in symptomatic patients with >50% stenosis if the perioperative stroke/death rate is <6% [A], preferably within 2 weeks of the patient's last symptoms [A]. CEA is also recommended in asymptomatic men <75 years old with 70-99% stenosis if the perioperative stroke/death risk is <3% [A]. The benefit from CEA in asymptomatic women is significantly less than in men [A]. CEA should therefore be considered only in younger, fit women [A]. Carotid patch angioplasty is preferable to primary closure [A]. Aspirin at a dose of 75-325 mg daily and statins should be given before, during and following CEA. [A] Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients, in high-volume centres with documented low peri-operative stroke and death rates or inside a randomized controlled trial [C]. CAS should be performed under dual antiplatelet treatment with aspirin and clopidogrel [A]. Carotid protection devices are probably of benefit [C].

  • 14. Matthiessen, Peter
    et al.
    Strand, Ida
    Jansson, Kjell
    Törnquist, Cathrine
    Andersson, Magnus
    Rutegård, Jörgen
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Is early detection of anastomotic leakage possible by intraperitoneal microdialysis and intraperitoneal cytokines after anterior resection of the rectum for cancer?2007In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 50, no 11, p. 1918-1927Article in journal (Refereed)
    Abstract [en]

    PURPOSE: This prospective study assessed methods of detecting intraperitoneal ischemia and inflammatory response in patients with and without postoperative complications after anterior resection of the rectum. METHODS: In 23 patients operated on with anterior resection of the rectum for rectal carcinoma, intraperitoneal lactate, pyruvate, and glucose levels were monitored postoperatively for six days by using microdialysis with catheters applied in two locations: intraperitoneally near the anastomosis, and in the central abdominal cavity. A reference catheter was placed subcutaneously in the pectoral region. Cytokines, interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha, were measured in intraperitoneal fluid by means of a pelvic drain for two postoperative days. RESULTS: The intraperitoneal lactate/pyruvate ratio near the anastomosis was higher on postoperative Day 5 (P = 0.029) and Day 6 (P = 0.009) in patients with clinical anastomotic leakage (n = 7) compared with patients without leakage (n = 16). The intraperitoneal levels of IL-6 (P = 0.002; P = 0.012, respectively) and IL-10 (P = 0.002; P = 0.041, respectively) were higher on postoperative Days 1 and 2 in the leakage group, and TNF-alpha was higher in the leakage group on Day 1 (P = 0.011). In-hospital clinical anastomotic leakage was diagnosed on median Day 6, and leakage after hospital discharge on median Day 20. CONCLUSIONS: The intraperitoneal lactate/pyruvate ratio and cytokines, IL-6, IL-10, and TNF-alpha, were increased in patients who developed symptomatic anastomotic leakage before clinical symptoms were evident.

  • 15.
    Mayer, D.
    et al.
    Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
    Aeschbacher, S.
    Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
    Pfammatter, T.
    Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
    Veith, F. J.
    The Cleveland Clinic, Cleveland OH, USA; New York University Medical Center, New York, USA.
    Norgren, Lars
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Magnuson, A.
    Clinical Epidemiology and Biostatistic Unit, Örebro University Hospital, Örebro, Sweden.
    Rancic, Z.
    Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
    Lachat, M.
    Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
    Larzon, Thomas
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: a two-center 14-year experience2012In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 256, no 5, p. 688-696Article in journal (Refereed)
    Abstract [en]

    Objective: To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months.

    Background: : Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair.

    Methods: We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an "EVAR-whenever-possible" approach until April 2009 (EVAR/OPEN period) and thereafter according to a "100% EVAR" approach (EVAR-ONLY period).Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2.

    Results: Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4-7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9-16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3-3.7).

    Conclusions: The "EVAR-ONLY" approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.

  • 16.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Betydelsefulla ändringar i etikprövningslagen2008In: Svensk kirurgi, ISSN 0346-847X, Vol. 66, no 4, p. 158-159Article in journal (Other academic)
  • 17.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Can preoperative unfractionated heparin be replaced by a low molecular weight heparin?2008In: Controversies and updates in vascular surgery 2008 / [ed] J.-P. Becqmin, Y. Alimi, J. L. Gérard, Torino: Edizioni Minerva Medica , 2008, p. 137-139Conference paper (Other academic)
  • 18.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    TASC II, an efficient decision tool?2009In: Controversies and updates in vascular surgery / [ed] Jean-Pierre Becquemin, Yves S Alimi, Jean-Luc Gérard, Torino: Edizioni Minerva , 2009, p. 287-290Chapter in book (Other academic)
  • 19.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    TASC II skall ge bättre vård: nytt internationellt konsensusdokument om perifer artärsjukdom ; medicinsk kommentar2007In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 104, no 19, p. 1474-1475Article in journal (Refereed)
  • 20.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hiatt, W. R.
    Dormandy, J. .A
    Nehler, M. R.
    Harris, K. A.
    Fowkes, F. G. R.
    Inter-society consensus for the management of peripheral arterial disease (TASC II)2007In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 45, no Suppl S, p. S5-S67Article in journal (Refereed)
  • 21.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hiatt, W. .R
    Dormandy, J. A.
    Nehler, M. .R
    Harris, K. A.
    Fowkes, F. G. R.
    Bell, Kevin
    Caporusso, Joseph
    Durand-Zaleski, Isabelle
    Komori, Kimihiro
    Lammer, Johannes
    Liapis, Christos
    Novo, Salvatore
    Razavi, Mahmood
    Robbs, Johns
    Schaper, Nicholaas
    Shigematsu, Hiroshi
    Sapoval, Marc
    White, Christopher
    White, John
    Clement, Denis
    Creager, Mark
    Jaff, Michael
    Mohler, Emile
    Rutherford, Robert B.
    Sheehan, Peter
    Sillesen, Henrik
    Rosenfield, Kenneth
    Inter-society consensus for the management of peripheral arterial disease (TASC II)2007In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 33 Suppl 1, p. S1-S75Article in journal (Refereed)
  • 22.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hiatt, W. R.
    Dormandy, J. A.
    Nehler, M. R.
    Harris, K. A.
    Fowkes, F. G. R.
    Rutherford, R. B.
    Inter-society consensus for the management of peripheral arterial disease2007In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 26, no 2, p. 81-157Article in journal (Refereed)
  • 23.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hiatt, William R.
    Why TASC II?2007In: Vascular Medicine, ISSN 1358-863X, E-ISSN 1477-0377, Vol. 12, no 4, p. 327-Article in journal (Refereed)
  • 24.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hiatt, William R.
    Harris, Kenneth A.
    Lammer, Johannes
    TASC II section F on revascularization in PAD2007In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 14, no 5, p. 743-744Article in journal (Refereed)
  • 25.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences.
    Endovascular repair of the ruptured abdominal aortic aneurysm2008In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 97, no 2, p. 178-181; discussion 181-2Article in journal (Refereed)
    Abstract [en]

    The present knowledge on endovascular repair of ruptured abdominal aortic aneurysms (rAAA) prevents firm conclusions when to use this method in comparison to open repair. This review article briefly summarizes results from case series, and discusses how to achieve reliable information despite the absence of randomized controlled trials. At present a careful conclusion might be that dedicated centers with an adequate organization and reasonably high volume of abdominal aortic aneurysm (AAA) should use detailed registry protocols to achieve experience and data to create an as reliable basis as possible for future recommendations.

  • 26.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences.
    Endovascular repair of the ruptured abdominal aortic aneurysm: editorial2008In: Vascular Medicine, ISSN 1358-863X, E-ISSN 1477-0377, Vol. 13, no 1, p. 45-46Article in journal (Refereed)
  • 27.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Myhre, Hans O.
    Arteriell insuffisiens i beina2007In: Tidsskrift for Den norske lægeforening, ISSN 0029-2001, E-ISSN 0807-7096, Vol. 127, no 16, p. 2123-Article in journal (Refereed)
  • 28. Novo, S.
    et al.
    Balbarini, A.
    Belch, J. J.
    Bonura, F.
    Clement, D. L.
    Diamantopoulos, E.
    Fareed, J.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Poredos, P.
    Rotzocil, K.
    The metabolic syndrome: definition, diagnosis and management2008In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 27, no 3, p. 220-31Article in journal (Refereed)
  • 29.
    Skoog, Per
    et al.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer. F.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Dept Surg, Orebro Univ Hosp, Orebro, Sweden.
    Larzon, Thomas
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Dept Surg, Orebro Univ Hosp, Orebro, Sweden.
    Abdominal Hypertension and Decompression: The Effect on Peritoneal Metabolism in an Experimental Porcine Study2014Manuscript (preprint) (Other academic)
    Abstract [en]

    Objective: This study aims to investigate the abdominal metabolic response and circulatory changes after decompression of intra-abdominal hypertension in a porcine model. Design: Prospective study with controls. Setting: University hospital research laboratory.

    Subjects: Three-months old domestic pigs of both sexes. Interventions: The animals were anesthetised and ventilated. Nine animals had a pneumoperitoneum-induced intra-abdominal hypertension of 30 mmHg for six hours. Twelve animals had corresponding intra-abdominal hypertension for four hours followed by decompression and were monitored for another two hours.

    Measurements and Main Results: Hemodynamics, urine output and arterial blood samples were analysed. Laserdoppler measured mucosal blood flow and urine output decreased with pressure induction and showed a statistically significant restitution after decompression. Glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured by microdialysis. Both groups developed distinct metabolic changes intraperitoneally at pressure induction including an increased l/p ratio as signs of organ hypoperfusion. In the decompression group the intraperitoneal l/p ratio normalised during the second decompression hour, indicating partially restored perfusion.

    Conclusions: Decompression after four hours of intra-abdominal hypertension results in restoration of intestinal blood flow and normalised intraperitoneal metabolism.

  • 30.
    Skoog, Per
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Ågren, Göran
    Department of Surgery Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Surgery Örebro University Hospital, Örebro, Sweden.
    Janson, Kjell
    Department of Surgery Örebro University Hospital, Örebro, Sweden.
    Intra-abdominal hypertension: exploration of early changes in intra-abdominal metabolism in a porcine modelManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To investigate the early effects of intra-abdominal hypertension on intraabdominal metabolism and intestinal mucosal blood flow.

    Design: Prospective animal study.

    Setting: University hospital research laboratory.

    Subjects: Three-month old domestic pigs of both sexes.

    Interventions: The animals were anesthetized and ventilated. Fifteen animals were subjected to intra-abdominal hypertension of 30 mmHg for four hours by carbon dioxide insufflation. Seven animals served as controls.

    Measurements and Main Results: Hemodynamic data, arterial blood samples and urine output were analyzed. Intraluminal laserdoppler flowmetry measured intestinal mucosal blood flow. Glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured intraperitoneally and intramurally in the small intestine and rectum by microdialysis. Intra-abdominal hypertension lowered the abdominal perfusion pressure by 12- 18 mmHg, reduced the intestinal mucosal blood flow by 45-63% and decreased urine output by 50-80%. While controls remained stable, glycerol concentrations increased at all locations at elevated intra-abdominal pressure, .pyruvate concentrations decreased and the l/p ratio increased intraperitoneally and intramurally in the small intestine. Glucose and lactate concentrations at all locations were only slightly affected or unchanged in both groups.

    Conclusions: Intra-abdominal hypertension negatively influences intestinal blood flow and diuresis and causes early metabolic changes, indicating a discrete shift towards anaerobic metabolism. Metabolic changes, measured by intra-abdominal microdialysis, preferably by an intraperitoneal catheter, might be used as early markers of impaired visceral organ function in intra-abdominal hypertension and abdominal compartment syndrome.

  • 31.
    Skoog, Per
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Deparment of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Deparment of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Region Örebro County, Örebro, Sweden.
    Ågren, Göran
    Deparment of Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Örebro University Hospital. Deparment of Surgery, Örebro University Hospital, Region Örebro County, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Humanities, Education and Social Sciences. Deparment of Surgery, Örebro University Hospital, Örebro, Sweden.
    Intra-Abdominal Metabolism and Blood Flow During Abdominal Hypertension: A Porcine Pilot Study Under Intravenous Anaesthesia2013In: Archives Of Clinical Experimental Surgery, ISSN 2146-8133, Vol. 2, no 3, p. 176-185Article in journal (Refereed)
    Abstract [en]

    Objective: To study the splanchnic metabolism and intestinal circulation in a porcine model with increased abdominal pressure.

    Methods: In an experimental porcine study, performed under intravenous anaesthesia, five animals were subjected to gradually increasing intra-abdominal pressure (15 mmHg, 25 mmHg, and 35 mmHg) with pneumoperitoneum. Microdialysis and laser Doppler were the main outcome methods for monitoring the metabolic and circulatory changes.

    Results: During stable anaesthesia and gradually increasing intra-abdominal pressure obtained by CO2-pneumoperitoneum, blood flow (microcirculation) was deprived and moderate signs of impaired splanchnic metabolism were recorded.

    Conclusions: The model appears usable for studies of splanchnic metabolic consequences of intra-abdominal hypertension.

1 - 31 of 31
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