Six Cases of Diabetic Foot Wounds with Concomitant Skin Malignancies / 대한족부족관절학회지

Diabetic foot wounds have a significant effect on the health-related quality of life of patients. As diabetic foot wounds are usually chronic and recurrent, it is possible that they can lead to skin malignancies. Several factors can make it difficult to make an early and accurate diagnosis of skin malignancies of the foot in patients with diabetes mellitus. Even though the prevalence of diabetes mellitus and diabetic foot wounds is increasing, currently there are no guidelines for the biopsy of diabetic foot wounds. We have evolved a criterion for the above based on six cases of diabetic foot wounds with concomitant skin malignancies. We recommend that clinicians should broadly consider implementing this criterion when managing patients with diabetic foot wounds.

Clinical Manifestations of Symptomatic Spontaneous Dissection of the Celiac and Superior Mesenteric Arteries

Purpose@#Spontaneous isolated dissection of the celiac artery (SID-CA) and superior mesenteric artery (SID-SMA) are rare vascular diseases with similar presentation, yet comparative studies have not been reported. In this study, we compared their characteristics with the aim of providing insights into their etiology. @*Materials and Methods@#Patients diagnosed with symptomatic SID-CA and SIDSMA between July 2009 and December 2018 were included. Demographics, clinical presentation, radiologic findings, treatment strategies, and outcomes were analyzed. @*Results@#Twenty-one patients with SID-CA and 40 patients with SID-SMA were compared. Demographics and initial abdominal pain characteristics were similar, but pain severity was significantly higher and associated mean fasting time was significantly longer in patients with SID-CA than in those with SID-SMA (fasting time 3.2 vs 2.1 days, P=0.001). Most patients were successfully treated conservatively without recurrent pain or aneurysmal dilatation, but 33.3% patients with SID-CA and 17.5% with SID-SMA required endovascular intervention. More favorable remodeling in terms of dissection regression on follow-up computed tomography was found after stenting, where patients with SID-CA showed better remodeling than those with SID-SMA. The overall median follow-up period was 22-31 months, while for patients with stent insertion, it was 55-77 months, and no stent occlusions were found during this period. @*Conclusion@#Patients with SID-CA presented with severer and longer-duration abdominal pain than those with SID-SMA. Stenting in both groups showed good long-term patency and favorable remodeling, with a higher regression rate for SIDCA. Based on our results, patients with SID-CA may benefit more from active endovascular intervention.

Paraplegia after Open Repair of Suprarenal Abdominal Aortic Aneurysm

Spinal cord ischemia after open repair of abdominal aortic aneurysm (AAA) is an unpredictable and devastating complication. We present a case report of a patient who developed paraplegia 6 hours after open repair of suprarenal AAA. A 74-yearold man presented with asymptomatic 5.5-cm suprarenal AAA, for which he underwent open repair under general anesthesia. The paraplegia was identified 6 hours after the operation. Postoperative magnetic resonance imaging showed T2 signal hyperintensity and swelling of the spinal cord, which were consistent findings with subacute spinal cord infarction. Although intravenous steroid was administered and lumbar cerebral spinal fluid drainage was instituted, his neurological outcome did not improve. He was discharged after vigorous rehabilitation but still has paraplegia and requires wheelchair for ambulation.

Clinical Manifestations of Symptomatic Spontaneous Dissection of the Celiac and Superior Mesenteric Arteries

Purpose@#Spontaneous isolated dissection of the celiac artery (SID-CA) and superior mesenteric artery (SID-SMA) are rare vascular diseases with similar presentation, yet comparative studies have not been reported. In this study, we compared their characteristics with the aim of providing insights into their etiology. @*Materials and Methods@#Patients diagnosed with symptomatic SID-CA and SIDSMA between July 2009 and December 2018 were included. Demographics, clinical presentation, radiologic findings, treatment strategies, and outcomes were analyzed. @*Results@#Twenty-one patients with SID-CA and 40 patients with SID-SMA were compared. Demographics and initial abdominal pain characteristics were similar, but pain severity was significantly higher and associated mean fasting time was significantly longer in patients with SID-CA than in those with SID-SMA (fasting time 3.2 vs 2.1 days, P=0.001). Most patients were successfully treated conservatively without recurrent pain or aneurysmal dilatation, but 33.3% patients with SID-CA and 17.5% with SID-SMA required endovascular intervention. More favorable remodeling in terms of dissection regression on follow-up computed tomography was found after stenting, where patients with SID-CA showed better remodeling than those with SID-SMA. The overall median follow-up period was 22-31 months, while for patients with stent insertion, it was 55-77 months, and no stent occlusions were found during this period. @*Conclusion@#Patients with SID-CA presented with severer and longer-duration abdominal pain than those with SID-SMA. Stenting in both groups showed good long-term patency and favorable remodeling, with a higher regression rate for SIDCA. Based on our results, patients with SID-CA may benefit more from active endovascular intervention.

Paraplegia after Open Repair of Suprarenal Abdominal Aortic Aneurysm

Spinal cord ischemia after open repair of abdominal aortic aneurysm (AAA) is an unpredictable and devastating complication. We present a case report of a patient who developed paraplegia 6 hours after open repair of suprarenal AAA. A 74-yearold man presented with asymptomatic 5.5-cm suprarenal AAA, for which he underwent open repair under general anesthesia. The paraplegia was identified 6 hours after the operation. Postoperative magnetic resonance imaging showed T2 signal hyperintensity and swelling of the spinal cord, which were consistent findings with subacute spinal cord infarction. Although intravenous steroid was administered and lumbar cerebral spinal fluid drainage was instituted, his neurological outcome did not improve. He was discharged after vigorous rehabilitation but still has paraplegia and requires wheelchair for ambulation.

Implementation of a resident night float system in a surgery department in Korea for 6 months: electronic medical record-based big data analysis and medical staff survey

PURPOSE: To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction. METHODS: A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems. RESULTS: A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial. CONCLUSION: This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.

Early experiences of endovascular aneurysm repair for ruptured abdominal aortic aneurysms

PURPOSE: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea. METHODS: We retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed. RESULTS: We identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS. CONCLUSION: Despite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.

Treatment options for isolated iliac artery aneurysms and their impact on aortic diameter after treatment

PURPOSE: Isolated iliac artery aneurysm (IIAA) is uncommon. It is frequently treated by endovascular aneurysm repair (EVAR). This study was to evaluate treatment results of IIAA and survey aortic diameter after EVAR. METHODS: Patients treated for IIAA in Seoul St. Mary's Hospital and Bundang Seoul National University from 2005 to April 2016 were retrospectively enrolled. The inclusion criteria of IIAA was >30 mm of iliac artery aneurysm without abdominal aortic aneurysm, which was treated by open surgical repair (OSR) or EVAR. Patients' clinical characteristics, treatment results, and mortality were obtained from electronic medical records. Diameters of aorta and iliac arteries were measured periodically with scheduled interval based on CT scans. RESULTS: Forty-nine patients (40 males; mean age, 71.9 ± 11.1 years) were enrolled. Five ruptured IIAAs were treated with EVAR (n = 1) or hybrid methods (n = 4). The diameter of ruptured IIAAs was 65 ± 31.4 mm, which was not significantly different from that of elective (44.3 ± 17.0 mm). Forty-four elective IIAA underwent 9 OSR, 31 EVARs, and 3 hybrid treatments (15 bifurcated and 12 straight stent-grafts). Treatment success rate was 93.8% without hospital mortality. There were 4 type I endoleak, 1 type II endoleak, and 1 type III endoleak without aneurysm-related mortality during follow-up. However, the aortic diameter was increased over time though there was no change or decrease in common iliac artery's diameter. CONCLUSION: Treatment of IIAA included various endovascular modalities as well as open surgery. Regular surveillance is still needed due to aortic dilatation after its treatment.

Access site pseudoaneurysms after endovascular intervention for peripheral arterial diseases

PURPOSE: Pseudoaneurysms after percutaneous vascular access are common and potentially fatal if left untreated. The aim of this study was to determine the incidence and risk factors associated with access site pseudoaneurysms after endovascular intervention for peripheral arterial disease (PAD) under a routine postintervention ultrasound (US) surveillance protocol. METHODS: A total of 254 PAD interventions were performed in a single center between January 2015 and November 2016, and puncture site duplex US surveillance was routinely performed within 48 hours of the procedure. Clinical, procedural and follow-up US data were analyzed. RESULTS: The overall incidence of pseudoaneurysm was 2.75% (6 cases in the femoral artery and 1 in the brachial artery). There was no difference between retrograde and antegrade approach, but there was a higher rate of pseudoaneurysm formation after manual compression compared to arterial closure device (ACD) use (4.3% vs. 0.87%). Manual compression was more commonly used for antegrade punctures (79.0%) and ACD for retrograde punctures (67.7%). Calcification was more frequently found in antegrade approach cases (46.8% vs. 16.9% for retrograde cases) and manual compression was preferred in its presence. All pseudoaneurysms were treated successfully at the time of diagnosis by US-guided compression repair and there were no cases of rupture. CONCLUSION: Pseudoaneurysm rates after therapeutic endovascular intervention for PAD were comparable to other cardiologic or interventional radiologic procedures despite the higher possibility of having a diseased access vessel. Routine US surveillance of access sites allowed for early diagnosis and noninvasive treatment of pseudoaneurysms, preventing potentially fatal complications.

Early Experiences of Sandwich Technique to Preserve Pelvic Circulation during Endovascular Aneurysm Repair

PURPOSE: To report experiences of the sandwich technique (ST) for preservation of pelvic flow during endovascular repair of complex aortic or aortoiliac aneurysms. MATERIALS AND METHODS: Eight patients underwent elective endovascular aneurysm repair (EVAR) using the ST between March 2013 and February 2017. The anatomic indications for the ST were complex aortoiliac aneurysms (5 cases), abdominal aortic aneurysms (AAA) with non-diseased short common iliac arteries (2 cases) and AAA with unilateral occluded iliac artery (1 case). The ST was performed through both femoral and brachial approach. Patient clinical and radiologic data were collected and analyzed. RESULTS: Eight patients (7 male; mean age, 73.4 years) were followed over a mean period of 277 days (range, 9–1,106 days). The technical success rate was 100%. The primary patency rate of the iliac stent-grafts was 88% (14/16 cases). One internal iliac and 1 external iliac stent-graft occlusion was observed during the early postoperative period. There was 1 gutter endoleak which disappeared spontaneously within 4 days, and there were 2 type II endoleaks: one treated by coil embolization after 13 months, and the other observed without treatment. There were no cases of sac growth or aneurysm-related deaths, and no cases of buttock claudication or impotence. CONCLUSION: The ST is a safe and feasible technique to preserve pelvic circulation during endovascular treatment of complex aortoiliac aneurysms. The need to expand the indications for complex EVARs with adjunctive procedures, such as the ST is highlighted in situations where branched/fenestrated device availability is limited.

Validation of the Korean version of the walking impairment questionnaire in patients with peripheral arterial disease

PURPOSE: Intermittent claudication is the most common early symptom of peripheral arterial occlusive disease. Walking impairment questionnaire (WIQ) is a short, inexpensive, easy-to-complete questionnaire to assess intermittent claudication and can provide data of usual walking. The purpose of this study is to validate the new Korean version of WIQ. METHODS: Total 51 patients with claudication were enrolled. While 4 patients were dropped out, 47 patients with claudication into were divided groups based on the treatment received: surgery (n = 33) and medication (n = 14). The surgery group was subdivided into the bypass (n = 13) and intervention (n = 20) groups. WIQ score, ankle-brachial index (ABI), and treadmill test scores were assessed initially and after 12 weeks. RESULTS: The WIQ scores were significantly correlated with ABI and pain-free walking distance (PFWD) and maximum walking distance (MWD) in all groups (except for MWD in the intervention group). Speed and stair-climb scores (2 WIQ domains) were well correlated with ABI, PFWD, and MWD. Distance scores were mostly correlated with ABI, PFWD, and MWD in all groups except ABI in the bypass and intervention groups and MWD in the bypass group. Reproducibility was observed in all groups (intraclass correlation coefficient > 0.8). CONCLUSION: The Korean version of the WIQ is valid and reproducible, and can be effectively used to assess Korean patients with intermittent claudication.

Factors Affecting Length of Hospital Stay and Mortality in Infected Diabetic Foot Ulcers Undergoing Surgical Drainage without Major Amputation

This study aimed to investigate factors affecting length of hospital stay and mortality of a specific group of patients with infected diabetic foot ulcer who underwent surgical drainage without major amputation, which is frequently encountered by orthopedic surgeons. Data on length of hospital stay, mortality, demographics, and other medical information were collected for 79 consecutive patients (60 men, 19 women; mean age, 66.1 [SD, 12.3] yr) with infected diabetic foot ulcer who underwent surgical drainage while retaining the heel between October 2003 and May 2013. Multiple linear regression analysis was performed to determine factors affecting length of hospital stay, while multiple Cox regression analysis was conducted to assess factors contributing to mortality. Erythrocyte sedimentation rate (ESR, P=0.034), glycated hemoglobin (HbA1c) level (P=0.021), body mass index (BMI, P=0.001), and major vascular disease (cerebrovascular accident or coronary artery disease, P=0.004) were significant factors affecting length of hospital stay, whereas age (P=0.005) and serum blood urea nitrogen (BUN) level (P=0.024) were significant factors contributing to mortality. In conclusion, as prognostic factors, the length of hospital stay was affected by the severity of inflammation, the recent control of blood glucose level, BMI, and major vascular disease, whereas patient mortality was affected by age and renal function in patients with infected diabetic foot ulcer undergoing surgical drainage and antibiotic treatment.

Rescue Therapy of Inadvertent Coil Migration for Endovascular Treatment of Type II Endoleak

Coil migration during endovascular procedures is not an unusual complication, but there is no standard management strategy for bailout. Here, we describe a technique for removal of a migrated coil using a snare. During embolization of type II endoleak from the inferior mesenteric artery in a post-endovascular aneurysm repair patient, the coil migrated to the sigmoidal artery causing an occlusion. We used a microsnare loop and successfully retrieved the migrated coil. This is the first case in Korea that uses a loop snare for the removal of a migrated coil during visceral endovascular treatment to our knowledge. This technique of using a microsnare for removal of displaced coils can be a good resort in selected cases.

An Intraosseous Epidermoid Cyst That Originated from the Nail Bed of Great Toe with Concurrent Joint Infection: A Case Report / 대한족부족관절학회지

We report on a rare case of an intraosseous epidermoid cyst in the distal phalanx of the great toe with concurrent infection in a 71-year-old woman with diabetes mellitus. The lesion was initially considered simple infectious arthritis and concomitant osteomyelitis in a patient with diabetes. However, after surgery, an intraosseous epidermoid cyst originating from the nail bed and involving the articular surface of the distal phalanx was detected. The epidermoid cyst may have contributed to the infectious arthritis in the interphalangeal joint. The lesion was treated via mass excision, arthrotomy, debridement, and intravenous antibiotics.

Spontaneous Renal Artery Dissection Complicated by Renal Infarction: Three Case Reports

Spontaneous renal artery dissection (SRAD) is a rare disease entity. The diagnosis is usually delayed because clinical presentation is non-specific. We report three cases of symptomatic SRAD complicated by renal infarction which occurred in previously healthy middle-aged male patients. They visited the hospital due to acute abdominal or flank pain. They had no specific underlying disease or trauma history. The laboratory tests and physical examination were normal. They were not suspected of having SRAD initially, but computed tomography (CT) revealed dissection of the renal artery with distal hypoperfusion leading to renal infarction. They were treated conservatively with anticoagulation and/or antiplatelets for 6 months. They had a 6-month regular follow-up with CT, where resolution was confirmed in one patient and all patients remained asymptomatic. These cases emphasize the importance of clinical suspicion of SRAD in previously healthy patients who complain of abdominal pain without specific findings on initial investigation.

Chronological Change of the Sac after Endovascular Aneurysm Repair

PURPOSE: The purpose of this study was to evaluate the potential risk factors of type II endoleak and sac growth after endovascular aneurysm repair (EVAR) and the outcomes of secondary interventions. MATERIALS AND METHODS: Ninety seven patients underwent elective EVAR for infrarenal abdominal aortic aneurysms in two tertiary centers between April 2005 and July 2013. Clinical and imaging parameters were compared among sac growth (>5 mm) and non-growth groups. Risk factors associated with sac growth and persistent type II endoleak were analyzed. The outcomes of reinterventions for persistent type II endoleak were determined. RESULTS: Sac growth was observed in 20 cases (20.6%) and endoleak was found in 90% of them compared to 28.6% (22/77) in the non-growth group (P<0.001). The majority of endoleaks were type II (36/40) and 80.5% were persistent. Sac diameter, neck diameter and number of patent accessory arteries were also statistically significant for sac growth. On multivariate analysis, grade of calcification at the neck, grade of mural thrombus at the inferior mesenteric artery and number of patent accessory arteries were risk factors of persistent type II endoleak. Twenty six reinterventions were done for 16 patients with persistent type II endoleak, with a technical success rate of 88.5%, yet 55.5% showed sac growth regardless of technical success. There were no ruptures during the follow-up period. CONCLUSION: Sac growth after EVAR was mostly associated with persistent type II endoleak. Secondary interventions using transarterial embolization is partially effective in achieving clinical success.

Recent Advances in the Development of Experimental Animal Models Mimicking Human Aortic Aneurysms

Aortic aneurysm is a common and life-threatening disease that can cause death from rupture. Current therapeutic options are limited to surgical or endovascular procedures because no pharmacological approaches have been proven to decrease the chance of expansion or rupture. The best approach to the management of aortic aneurysm would be the understanding and prevention of the processes involved in disease occurrence, progression, and rupture. There is a need for animal models that can reproduce the pathophysiological features of human aortic aneurysm, and several such models have been studied. This review will emphasize recent advances in animal models used in the determination of mechanisms and treatments of aortic aneurysms.

Resuscitative Endovascular Balloon Occlusion of the Aorta in a Trauma Patient with Hypovolemic Shock / 대한중환자의학회지

Hemorrhagic shock is one of the most common causes of death in patients with multiple trauma and therefore rapid control of bleeding is the main strategy to save these patients. Resuscitative balloon occlusion of the aorta (REBOA) has been applied in several trauma cases and because of the effectiveness of this procedure it has been adopted in the trauma field. Herein, we report the first successful case of REBOA in Korea performed on a 46-year-old man with hemorrhagic shock after a fall from a height of 14-stories. The patient visited our hospital emergency room with hypovolemic shock, we performed Resuscitative Endovascular Balloon Occlusion of the Aorta under bed side blind technique. His vital sign was stabilized after procedure, then we could performed endovascular bleeding control. The patient was discharged on his 33rd in-hospital day without invasive procedure and major scar.

Spontaneous Iliac Vein Rupture

Spontaneous iliac vein rupture (SIVR) is a rare entity, which usually occurs without a precipitating factor, but can be a life-threatening emergency often requiring an emergency operation. This is a case report of SIVR in a 62-year-old female who presented to the emergency room with left leg swelling. Workup with contrast-enhanced computed tomography revealed a left leg deep vein thrombosis with May-Thurner syndrome and a hematoma in the pelvic cavity without definite evidence of arterial bleeding. She was managed conservatively without surgical intervention, and also underwent inferior vena cava filter insertion and subsequent anticoagulation therapy for pulmonary thromboembolism. This case shows that SIVR can be successfully managed with close monitoring and conservative management, and anticoagulation may be safely applied despite the patient presenting with venous bleeding.

Resuscitative Endovascular Balloon Occlusion of the Aorta in a Trauma Patient with Hypovolemic Shock / 대한구급학회지

Hemorrhagic shock is one of the most common causes of death in patients with multiple trauma and therefore rapid control of bleeding is the main strategy to save these patients. Resuscitative balloon occlusion of the aorta (REBOA) has been applied in several trauma cases and because of the effectiveness of this procedure it has been adopted in the trauma field. Herein, we report the first successful case of REBOA in Korea performed on a 46-year-old man with hemorrhagic shock after a fall from a height of 14-stories. The patient visited our hospital emergency room with hypovolemic shock, we performed Resuscitative Endovascular Balloon Occlusion of the Aorta under bed side blind technique. His vital sign was stabilized after procedure, then we could performed endovascular bleeding control. The patient was discharged on his 33rd in-hospital day without invasive procedure and major scar.