Anastomotic stenting in a porcine aortoiliac graft model.

The purpose of the study was to evaluate the feasibility of anastomotic stent application in a porcine aortoiliac graft model. In a total of 10 pigs, a polytetrafluoroethylene aortobi-iliac graft was implanted through a midline abdominal incision. The lower edge of the iliac vessel was graft-inverted about 1 mm to produce irregularities at the downstream anastomosis. After transverse graft incision, six stainless-steel stents, six poly-L-lactic acid (PLLA) stents and four PLLA stents with 10% polycaprolactone (PCL) were implanted at the iliac anastomotic site using a 6 mm balloon dilatation catheter. Four anastomotic sites were left untreated. After two weeks, the patency of graft limbs was evaluated by contrast-enhanced computed tomography (CT). Both metal and polymeric stent designs provided adequate flexibility to manoeuvre across the anastomotic site for expansion in the chosen position. After deployment, the stent-arterial wall contact was complete on a macroscopic view. On CT scan, all metal and PLLA-stented graft limbs were free of stenosis, whereas all PLLA/PCL stents were occluded. The non-stented graft limbs showed a stenosis of 50-70%. In summary, this model is feasible to assess preclinically the deployment and patency rate of an anastomotic stent and to test future stent developments.

Population management takes disease management to the next level.

The increased development and implementation of disease management programs reflect attempts by a growing number of health plans to reduce costs while providing patients with high-quality care. Unfortunately, few of these programs are generating optimal cost savings. Instituting initiatives for a select group of plan members afflicted with a disease will not produce the positive results that a comprehensive population management program can. Through the integration, coordination, and management of all of a population's healthcare needs, diabetes population management programs are producing significantly greater cost savings than are other disease management programs, including those for diabetes.

Transcutaneous oxygen as a predictor of wound healing in amputations of the foot and ankle.

Thirty-eight amputations of the foot and ankle were performed in patients with peripheral vascular insufficiency over a 20-month period. Amputation level selection was based on clinical examination, a minimum ankle-brachial index of 0.5 as a measure of vascular supply, serum albumin of 3.0 gm/dl as a measure of tissue nutrition, and a total lymphocyte count of 1500 as a measure of immunocompetence. Transcutaneous oxygen tension was measured at the midfoot and ankle levels prior to surgery. Thirty-two of 38 patients (84.2%) healed their amputation wounds. When the transcutaneous oxygen tension was greater than 30 mm Hg, 24 of 26 patients (92.3%) healed. When the value was below 30 mm Hg, only eight of 12 patients healed. When the propensity to support wound healing is factored out, with patients having the metabolic capacity to heal an amputation wound in the foot and ankle, it appears that transcutaneous oxygen tension is an accurate measure of vascular inflow to support amputation wound healing.

Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot.

Twelve patients who had a large ulceration over the heel were managed with a partial calcanectomy, in lieu of a below-the-knee amputation, after unsuccessful non-operative treatment of the ulcer. Only patients who had an ankle-arm index (the ratio of blood pressure at the ankle to the brachial blood pressure) of more than 0.45, a transcutaneous PO2 of more than twenty-eight millimeters of mercury (3.7 kilopascals), a level of albumin of more than 3.0 grams per deciliter (thirty grams per liter), and a total lymphocyte count of more than 1500 were managed with a partial calcanectomy. The primary diagnosis was diabetes in seven patients, peripheral vascular disease in three, quadriplegia in one, and myelodysplasia in one. The duration of follow-up averaged thirty-three months and ranged from seven to sixty-four months. The wound healed after the partial calcanectomy in ten of the twelve patients. Nine of these ten patients maintained the level of mobility that they had had preoperatively. (One patient was unable to walk because he was quadriplegic before the operation). The wound did not heal in two patients, and those patients ultimately had a below-the-knee amputation and a decrease of one grade on the scale that was used to evaluate walking ability.