The diabetic foot ulcer.

BACKGROUND: Diabetic foot ulcers are associated with significant morbidity and mortality and can subsequently lead to hospitalisation and lower limb amputation if not recognised and treated in a timely manner. OBJECTIVE: The aim of this article is to review the current evidence for preventing and managing diabetic foot ulcers, with the aim to increase clinicians' confidence in assessing and treating these complex medical presentations. DISCUSSION: All patients with diabetes should have an annual foot review by a general practitioner or podiatrist. A three-monthly foot review is recommended for any patient with a history of a diabetic foot infection. Assessment involves identification of risk factors including peripheral neuropathy and peripheral vascular disease, and examination of ulceration if present. It is essential to identify patients with diabetes who are 'at risk' of ulceration, assess for any early signs of skin breakdown, initiate appropriate management to prevent progression and refer the patient if indicated.

Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification.

BACKGROUND: Advances in endovascular technology have led to the successful treatment of complex abdominal aortic aneurysms. However, there is currently no consensus on what constitutes a juxtarenal, pararenal, or suprarenal aneurysm. There is emerging evidence that the extent of the aneurysm repair is associated with outcome. We compare the outcomes of 150 consecutive patients treated with a fenestrated or branched stent graft and present the data stratified according to the Society for Vascular Surgery classification based on proximal anatomic landing zones. METHODS: A prospectively collected database of consecutive patients undergoing fenestrated or branched stent graft insertion in a tertiary center between 2008 and 2013 was retrospectively analyzed. Aneurysms were subdivided into zones according to where the area of proximal seal could be achieved in relation to the visceral arteries. Zone 8 covers the renal arteries, zone 7 covers the superior mesenteric artery, and zone 6 covers the celiac axis. Patient demographics, operative variables, mortality, and major morbidity were analyzed by univariate and multivariate analysis to assess for differences between zones. RESULTS: During the study period, 150 patients were treated. There were 49 in zone 8, 76 in zone 7, and 25 in zone 6. Prior aortic surgery had been performed in 19 patients, which included 11 patients with previous endovascular aneurysm repairs. There was significantly increased blood loss (P < .001), operative time (P < .0001), total hospital stay (P = .018), and intensive care unit stay (P < .0001) as the zones ascended the aorta. There were 14 inpatient deaths recorded across all zones with a 30-day mortality rate of 8%. Logistic regression analysis for 30 day mortality showed a significant increase as the zones ascended (P = .007). Kaplan-Meier analysis showed that 5-year survival significantly deteriorated as the zones ascended (P = .039), with no significant difference in the freedom from reintervention curves between zones (P = .37). CONCLUSIONS: We have shown that the extent of the aneurysm repair as determined by the proximal sealing zone is associated with outcome. Mortality, operative duration, blood loss, and hospital stay all significantly increased as the zones ascended. These data also validate the use of the proposed new classification based on aortic anatomy.

Techniques for removing bilateral renal artery stents prior to fenestrated endovascular aneurysm repair.

PURPOSE: To demonstrate 2 endovascular methods for successful intravascular stent extraction. TECHNIQUE: In preparation for fenestrated endovascular aneurysm repair, renal artery stents may be implanted for focal vessel stenosis at the ostium. In a recent case, bilateral renal artery stents were deployed with >50% protruding into the aortic lumen, thus rendering fenestrated endografting impossible. Two techniques were employed to extract the stents. In the left renal artery, the stent was extracted using an endovascular snare, but the right renal artery stent could not be removed with this method. Instead, an endoscopic forceps was advanced down a 16-F sheath, and the stent was grasped, extracted, and released into the aneurysm sac. The endovascular repair then proceeded in the usual fashion. CONCLUSION: The need to remove a stent prior to endovascular aneurysm repair is not a common problem encountered by most endovascular specialists; however, these methods should be in their armamentarium should the need arise.

Early diagnosis and resection of an asymptomatic leiomyosarcoma of the inferior vena cava prior to caval obstruction.

Leiomyosarcoma of the inferior vena cava is a rare and aggressive tumor, characterized by a slow growth and usually late diagnosis. The mainstay of therapy is surgical resection with limited role for chemotherapy or radiotherapy; resection modalities and the need for caval reconstruction are still matters of debate. In this case report, we describe an asymptomatic intraluminal leiomyosarcoma of the inferior vena cava diagnosed incidentally prior to caval occlusion during a routine ultrasound examination of the upper abdomen.

Placement of a branched stent graft into the false lumen of a chronic type B aortic dissection.

The treatment of chronic type B aortic dissections remains challenging and controversial. Currently most centers advocate open or endovascular intervention for patients with evidence of malperfusion, rupture or impending rupture, continued pain, or aneurysm formation. Regardless of the type of intervention, the incidence of complications or death remains high, even when undertaken in an elective setting. The standard endovascular treatment usually involves placement of a stent graft into the true lumen of the dissection in an effort to exclude the false lumen. This case report describes the placement of a branched stent graft into the false lumen of a patient with chronic type B dissection to encourage exclusion and thrombosis of the true lumen whilst maintaining flow to all visceral vessels.