Intermittent compression pump for nonhealing wounds in patients with limb ischemia. The Mayo Clinic experience (1998-2000).

BACKGROUND: The aim of this retrospective observational study was to review the use of an intermittent pneumatic compression device on nonhealing wounds in patients with critical limb ischemia at Mayo Clinic Rochester. METHODS: The setting was a community and referral multidisciplinary wound care clinic. The authors analysed 107 patients, median age 73, with critical limb ischemia and active ulcers started using a compression device between 1998 and 2000; 101 patients had lower extremity ulcers, and 25% had a history of amputation, and 64% had diabetes. Of all the wounds, 64% were multifactorial in etiology, and 60% had associated transcutaneous oxygen tension levels below 20 mmHg. Patients were typically asked to use the device at home on the affected limb(s) for 6 hours daily. The main outcome criterion was complete wound healing with limb preservation. RESULTS: The median follow-up after initiation of treatment was 6 months. Complete wound healing with limb preservation was achieved by 40% of patients with TcPO(2) levels below 20 mmHg; by 48% with osteomyelitis or active wound infection; by 46% with diabetes treated with insulin; and by 28% with a previous amputation. Half of all amputations occurred in patients with prior amputations. Seven patients discontinued the device because of pain experienced with its use. CONCLUSIONS: Patients with critical limb ischemia and nonhealing wounds at high risk of amputation can achieve complete wound healing and limb preservation by using an intermittent pneumatic compression device.

Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study.

BACKGROUND: The incidence rates of venous stasis syndrome and venous ulcer are uncertain, and trends in incidence are unknown. METHODS: We performed a retrospective review of the complete (inpatient and outpatient) medical records of a community population (Olmsted County, Minnesota) to estimate the incidence of venous stasis syndrome and venous ulcer during the 25-year period, 1966 to 1990, and to describe trends in incidence. RESULTS: A total of 1131 patients received a first lifetime diagnosis of venous stasis syndrome. A total of 263 patients received a first lifetime diagnosis of venous ulcer. The overall incidence of venous stasis syndrome and venous ulcer were 76.1 and 18.0 per 100,000 person-years, respectively. The incidence of both was higher in women than in men (83.7 vs 67.4 per 100,000 person-years for venous stasis syndrome; 20.4 vs 14.6 per 100,000 for venous ulcer) and increased with age for both sexes. There was no clear trend in the incidence of venous stasis syndrome over the 25-year period. Compared with 1966 to 1970, the incidence of venous ulcer decreased in 1971 to 1980, but was unchanged after 1981. Among 945 patients with venous stasis only, 60 subsequently had a venous ulcer. The average (+/- SD) time from venous stasis diagnosis to development of a venous ulcer was 5.0 (+/- 5.0) years. CONCLUSION: Venous stasis syndrome and venous ulcer are common, especially in the elderly population. The incidence of venous stasis syndrome has not changed since 1966, and venous ulcer incidence is unchanged since 1981. More accurate identification of patients at risk for venous stasis syndrome and venous ulcer and more effective prevention are needed.

Surgical treatment of venous malformations in Klippel-Trénaunay syndrome.

PURPOSE: Klippel-Trénaunay syndrome (KTS) is a complex congenital anomaly, characterized by varicosities and venous malformations (VMs) of one or more limbs, port-wine stains, and soft tissue and bone hypertrophy. Venous drainage is frequently abnormal because of embryonic veins, agenesis, hypoplasia, valvular incompetence, or aneurysms of deep veins. We previously reported on the surgical management of KTS. In this article, we update our experience. METHODS: Twenty patients with KTS underwent surgical treatment for VMs between July 1, 1987, and January 1, 2000. This group represented 6.9% of 290 patients with KTS who were seen at our institution during this 12.5-year study period. Surgical indications, venous anatomy (determined with duplex scan, contrast phlebography, magnetic resonance imaging or magnetic resonance phlebography), operative procedures, and complications were reviewed, and outcomes were recorded. RESULTS: Twelve male and eight female patients (mean age, 23.4 years; range, 7.7-40.6 years) underwent 30 vascular surgical procedures in 21 lower limbs. All 20 patients (100%) had varicose veins or VMs, 13 (65%) had port-wine stains, and 18 (90%) had limb hypertrophy. Pain was the most common complaint, which was present in 16 patients (80%), followed by swelling in 15 (75%), bleeding in 8 (40%), and superficial thrombophlebitis and cellulitis in 3 (15%). Imaging confirmed patent deep veins in 18 patients, hypoplastic femoral vein in 1, and entrapped popliteal veins bilaterally in 1. Four patients (20%) had large persistent sciatic veins (PSVs). The CEAP clinical classification was C-3 for 17 patients (85%), C-4 for 1 patient (5%), and C-6 for 2 patients (10%). Stripping of large lateral veins, avulsion, and excision of varicosities or VMs were performed on all limbs. Three patients required staged resections. The release of entrapped popliteal veins was performed in both limbs of one patient; another underwent a popliteal-saphenous bypass graft. One patient underwent excision of a PSV. Open and endoscopic perforator vein ligation was performed in one patient each. Two patients (12%) had hematomas that required evacuation. No patients had caval filter placement; none had postoperative deep venous thrombosis or pulmonary embolus. The mean follow-up was 63.6 months (range, 0-138 months). All patients reported initial improvement, but some varicosities recurred in 10 patients (50%), an ulcer did not heal in one, and a new ulcer developed in one, 8 years after surgery. Three patients underwent reoperation for recurrent varicosities. Follow-up CEAP scores were C-2 in 10 patients (50%), C-3 in 6 patients (30%), C-4 and C-5 in 1 patient each (5%), and C-6 in 2 patients (10%). Clinical scores improved from 4.3 +/- 2.2 to 3.1 +/- 2.3. (P =.03). CONCLUSIONS: The management of patients with KTS continues to be primarily nonoperative, but those patients with patent deep veins can be considered for excision of symptomatic varicose veins and VMs. Although the recurrence rate is high, clinical improvement is significant, and reoperations can be performed if needed. Occasionally, deep vein reconstruction, excision of PSVs, or subfascial endoscopic perforator surgery is indicated. Because KTS is rare, patients should receive multidisciplinary care in qualified vascular centers.

Circulator boot therapy alters the natural history of ischemic limb ulceration.

Despite numerous advances in interventional radiology and vascular surgery, the clinician continues to be confronted with inoperable vascular disease. Previous studies have shown that ulceration associated with a transcutaneous oxygen pressure (tcPO2) of <20 mmHg is refractory to all attempts at healing. External pneumatic compression for the treatment of peripheral vascular disease has been available for several years, although there is a relative paucity of data regarding its role in clinical practice as well as its efficacy. The objective of this study was to examine the experience with circulator boot therapy in the treatment of ischemic ulcers in the absence of osteomyelitis, and specifically to determine whether such therapy can be of benefit in ischemic limb ulceration associated with a tcPO2 of <20 mmHg. A retrospective chart review was undertaken of ail patients with a lower limb ulcer who, in the absence of osteomyelitis, underwent circulator boot therapy at the Gonda Vascular Center. A total of 98 patients was identified. Two patients died within 1 month of commencing therapy and were not included in further analysis. The tcPO2 data were unavailable in five patients. Outcome in the patient population was classified as favorable if (1)healing was achieved, (2)the ulcer decreased in size, or (3) the affected limb improved sufficiently to allow successful revascularization. An unfavorable outcome was one where a major amputation was performed or where the ulcer increased in size. Out of a total of 29 patients with a tcPO2 <20 mmHg at the area of ulceration, 19 had a favorable outcome following circulator boot therapy. Of the remaining 62 patients with a tcPO2 >20 mmHg, 54 had a favorable outcome. Circulator boot therapy is associated with improved outcomes in limb ulceration due to peripheral vascular disease. Complete ulcer healing as well as preservation of the affected limb can be achieved in most cases.

Natural history of erythromelalgia: presentation and outcome in 168 patients.

OBJECTIVE: To describe the demographics, presentation, and outcome in patients with erythromelalgia--a rare and poorly understood clinical syndrome defined by the triad of red, hot, painful extremities. DESIGN: Retrospective medical record review with follow-up by survey questionnaire. SETTING: Large tertiary care medical center. SUBJECTS: Patients with erythromelalgia examined at the Mayo Clinic, Rochester, Minn, between 1970 and 1994. INTERVENTION: The medical records of 168 patients were analyzed. Follow-up data, which consisted of answers to 2 survey questionnaires or the most recent information in the medical record from patients still alive and death certificates or reports of death for those deceased patients, were obtained for all but 13 patients. MAIN OUTCOME MEASURES: Survival, morbidity, and quality of life. RESULTS: All patients were white; 122 (72.6%) were female, and 46 (27.4%) were male. At presentation, the patients' mean age was 55.8 years (age range, 5-91 years). Symptoms had been present since childhood in 7 patients (4.2%). Six patients (3.6%) had a first-degree relative with erythromelalgia. Symptoms were intermittent in 163 patients (97.0%) and constant in 5 (3.0%). Symptoms predominantly involved feet (148 patients [88.1%]) and hands (43 patients [25.6%]). Kaplan-Meier survival curves revealed a significant decrease in survival compared with that expected in persons of similar age and of the same sex (P<.001). After a mean follow-up of 8.7 years (range, 1.3-20 years), 30 patients (31.9%) reported worsening of, 25 (26.6%) no change in, 29 (30.9%) improvement in, and 10 (10.6%) complete resolution of the symptoms. On a standard health status questionnaire, scores for all but one of the health domains were significantly diminished in comparison with those in the US general population. CONCLUSION: Erythromelalgia is a syndrome with significantly increased mortality and morbidity compared with the US general population.

Lack of effect of coumarin in women with lymphedema after treatment for breast cancer.

BACKGROUND: Lymphedema of the arms can be a serious consequence of local and regional therapy in women with breast cancer. Coumarin has been reported to be effective for the treatment of women with lymphedema; we undertook a study in which we attempted to replicate those findings. METHODS: We studied 140 women with chronic lymphedema of the ipsilateral arm after treatment for breast cancer. The women received 200 mg of oral coumarin or placebo twice daily for six months and then the other treatment for the following six months. The end points of the study consisted of the volume of the arm (calculated from measurements of hand and arm circumference) and the answers on a questionnaire completed by the patient about symptoms potentially related to lymphedema. RESULTS: The volumes of the arms at 6 and 12 months, were virtually identical, regardless of whether coumarin or placebo was given first. After six months, the average volume of the affected arm increased by 21 ml during placebo treatment and 58 ml during coumarin treatment (P=0.80). In addition, answers to patient-completed questionnaires were similar in the two treatment groups. After six months only 15 percent of the women in the coumarin group and 10 percent of those in the placebo group reported that the study medication had helped a moderate or large amount (P=0.19). Coumarin was well tolerated, except that it resulted in serologic evidence of liver toxicity in 6 percent of the women. CONCLUSIONS: Coumarin is not effective therapy for women who have lymphedema of the arm after treatment for breast cancer.

Neurophysiologic and vascular studies in erythromelalgia: a retrospective analysis.

Erythromelaigia is a poorly understood clinical syndrome characterized by painful, hot, red extremities. We assessed the frequency and types of abnormalities observed during tests of vascular, peripheral neurophysiologic, and autonomic function in patients with erythromelalgia.Methods Of" 163 charts of patients fulfilling the clinical diagnosis of erythromelalgia. 93 patients underwent vascular studies Five of them had detailed vascular studies in 10 affected lower extremities performed before and during symptoms, fifty-four patients underwent neurophysiologic testing, 27 had autonomic reflex screening (ARS). and two had recordings of peripheral autonomic surface potentials (PASP).Results. Measurements in the toes during symptoms revealed a mean temperature increase of 11.6 C (P = 0,00011 along with a laser flow increase from a mean of 6.8 mL/min per 100 g tissue to 76.5 mL/min per 100 g tissue (P<.0.0001). Baseline TcPO; in the feet decreased by 6.7 mmHg (P = 0.032) during symptoms. Twenty-one of 54 electromyographic recordings were abnormal: all fulfilled the criteria for axonal neuropathy. Seventeen of 27 ARSs and one PASP showed severe postganglionic sudomotor impairment; five of 17 additionally had peripheral adrenergic dysfunction.Conclusions During symptoms, an increase in flow and temperature is accompanied paradoxically by a decrease in oxygenation of the affected area; a high proportion of patients have a distal small fiber neuropathy with selective involvement of cutaneous sympathetic fibers; in addition, large fiber neuropathy is often present.

Endoscopic perforator vein division with ablation of superficial reflux improves venous hemodynamics.

PURPOSE: Hemodynamic consequences of incompetent perforator vein interruption have not been well documented. The effects of perforator interruption, with or without ablation of superficial venous reflux, on venous function in patients with advanced chronic venous insufficiency was studied. METHODS: Calf muscle pump function, venous incompetence, and outflow obstruction were assessed by means of strain-gauge plethysmography (SGP) before and within 6 months after subfascial endoscopic perforator surgery (SEPS). SEPS was performed with laparoscopic instrumentation and CO2 insufflation. Concomitant high ligation or saphenous vein stripping was performed in 24 limbs (77%). RESULTS: Twenty-six patients, 18 women and 8 men, with a mean age of 50 years (range, 20 to 77 years) underwent SEPS. Preoperative evaluation confirmed superficial reflux in 65% of limbs, deep venous reflux in 77% of limbs, and perforator incompetence in 97% of limbs. All limbs had advanced venous dysfunction (C3, C4, C5, C6). All active ulcers (C6, n = 12) healed after surgery (mean, 32 +/- 3 days), and only 1 recurred during a mean follow-up period of 11 months (range, 1 to 43 months). Clinical score improved from 6.58 +/- 0.50 to 2.19 +/- 0.25 (P <.0001). Improved calf muscle pump function was demonstrated by means of postoperative SGP and was indicated by increased refill volume (RV: 0.27 +/- 0.06 vs 0.64 +/- 0.10 mL/100 mL tissue, P <.01). Venous incompetence also improved, as evidenced by prolonged duration to refill after exercise (T90: 7. 71 +/- 1.20 vs 16.71 +/- 1.98 seconds, P <.001) and a decrease in RV after passive drainage (3.23 +/- 0.19 vs 2.63 +/- 0.15 mL/100 mL tissue, P <.01). Improved refill rate (RR) correlated with improvements in clinical scores (P <.01, r = 0.77). CONCLUSION: SEPS with ablation of superficial reflux improved calf muscle pump function, reduced venous incompetence, and produced excellent midterm clinical results. However, functional improvement directly related to SEPS requires further investigation. This study supports adding SEPS to ablation of superficial reflux in patients with advanced chronic venous insufficiency.

The Mayo Vascular Center experience.

American medicine is trending toward an increasing number of specialty care centers. Cancer centers, transplant centers, and sports medicine centers are only a few common examples. Vascular centers are relatively new entities that are forming for obvious reasons. As the general population ages, peripheral vascular disease has become more prevalent. Several types of medical, surgical, and radiological specialists are involved in the diagnosis and treatment of such patients. Creating multispecialty vascular centers is one method to focus expert care on the patient, to alleviate some of the turf battles between specialties, and to contain burgeoning Medicare costs.

Factors affecting clinical outcome following endoscopic perforator vein ablation.

BACKGROUND: Despite good outcomes reported with minimally invasive, subfascial endoscopic perforator surgery (SEPS), some patients demonstrate poor healing or recurrence of venous ulcers. The goal of this study was to identify factors that lead to failure of SEPS. METHODS: Forty-eight consecutive patients who had undergone 57 SEPS procedures were analyzed. Mean follow-up was 17 +/- 2 months (range 2 weeks to 52 months). RESULTS: All active ulcers (n = 22) at the time of surgery healed in an average of 99 +/- 37 days (range 11 to 670). Eight limbs had poor healing of their ulcer (>40 days); five (9%) new/recurrent ulcers developed postoperatively. Deep venous obstruction was associated with delayed ulcer healing (316 +/- 171 versus 51 +/- 14 days, P < 0.01) and ulcer recurrence (P < 0.0001). Poor ulcer healing and recurrence were not associated with lipodermatosclerosis, edema, ulcer duration >3 months, or previous recurrences. Ulcer size >2 cm (P < 0.05) and combined ilio-femoral and popliteal/tibial reflux were associated with poor ulcer healing (P < 0.05). CONCLUSIONS: SEPS could not prevent recurrent or new ulceration in 9% of limbs. Venous outflow obstruction was associated with ulcer recurrence and prolonged ulcer healing. Multilevel deep venous reflux and ulcer size >2 cm were also associated with delayed healing.

A critical review of reflective practice in its role towards personal and professional development.

Reflection has become a prominent feature in today's nursing. Love it or hate it, the UK Central Council for Nurses, Midwives and Health Visitors stipulates that evidence of reflective practice is a requirement for both pre and post registration nurses. While reflection can assist in facing the increasing challenges of nursing, it can also present as a challenge in itself unless nurses have familiarised themselves with the process and feel at ease with it. The issues of reflective practice are explored to determine if it can enhance personal and professional development.

Technical and practical considerations involved in operations on patients weighing more than 270 kg.

Care of the patient with superobesity requires special precautions and appropriate equipment. Recently, we performed bariatric procedures (modified very-long-limb Rouxen-Y gastric bypass) on patients weighing 355 kg and 377 kg. These procedures required preoperative preparation concerning safe means of transport of the patient, techniques of anesthesia and intraoperative exposure, provisions for postoperative recovery, and measures to assure patient comfort and hygiene postoperatively. In addition to specially designed bariatric procedures for the superobese, specialized equipment is needed to protect the health of the patient and the staff. All health care providers and especially acute care centers must have preconceived protocols to treat the superobese patient. In addition, specialized equipment is necessary to allow safe transport and support of these patients.

Influence of coronary heart disease on morbidity and mortality after lower extremity revascularization surgery: a population-based study in Olmsted County, Minnesota (1970-1987).

OBJECTIVES: The aim of this study was to evaluate the short- and long-term postoperative cardiac outcome of patients undergoing lower extremity revascularization surgery in a geographically defined patient group. BACKGROUND: Among patients with peripheral vascular disease, cardiac events have an important effect on long-term outcome after peripheral vascular surgery. However, long-term outcome is poorly documented. METHODS: We examined the entire community medical records of 173 residents of Olmsted County, Minnesota, who underwent peripheral artery bypass surgery between 1970 and 1987 and were followed up to January 1, 1991. Patients were allocated to subgroups of 60 patients with and 106 patients without overt coronary artery disease. RESULTS: There were no significant differences in perioperative death, myocardial infarction or stroke between subgroups at 30 days after operation. The 5- and 10-year Kaplan-Meier survival rate after operation was 77% and 51% in those without and 54% and 24% in those with overt coronary artery disease (p < 0.001), respectively. For both groups, survival was significantly poorer than that expected for an age- and gender-matched group. Patients undergoing aortoiliac surgery were more likely to be alive at 10 years than those undergoing femoropopliteal surgery (47% vs. 28%, p = 0.001). The 5-year cumulative incidence of cardiac events was greater in those with overt coronary artery disease (50% vs. 28%, p = 0.003). In multivariable analysis, age, coronary artery disease and diabetes were independent predictors of death. CONCLUSIONS: Coronary events are the most important cause of long-term morbidity and mortality after peripheral vascular surgery. Patients without overt coronary artery disease are at significant risk for long-term cardiac events.

Microscope-aided pedal bypass is an effective and low-risk operation to salvage the ischemic foot.

BACKGROUND: The aim of this study was to determine the current operative risks of the pedal bypass procedure, its durability, and the factors affecting long-term outcome. METHODS: We prospectively observed 96 patients who consecutively underwent 100 pedal bypasses using autogenous vein grafts for chronic critical ischemia. Of the 100 limbs, 91 had ischemic ulcers or gangrene, and 9 produced rest pain only. Sixty-four patients were diabetic, 21 had renal failure, and 36 had coronary artery disease. Nonreversed saphenous vein grafts were used most frequently (68 translocated, 13 in situ), followed by composite (13) and reversed vein grafts (6). Fifty-two long grafts originated from the iliac or femoral arteries, and 48 short grafts originated from the popliteal or tibial arteries. For the 100 procedures, 102 distal anastomoses were performed--68 to the dorsalis pedis, 8 to the distal posterior tibial, 10 to the common plantar, 2 to the medial plantar, 9 to the lateral plantar, 4 to the lateral tarsal, and 1 to the first dorsal metatarsal arteries--with the aid of an operating microscope. RESULTS: No patient died during the perioperative period. Two had hemodynamically insignificant myocardial infarctions. Wound complications developed in 12 patients--infection in 7 and hematoma in 5. There were 10 early graft failures, 6 of which could be salvaged, and 96 grafts were patent at dismissal. Mean follow-up was 2.1 years (range 1 month to 6.4 years). Postoperative surveillance identified 33 failed or failing grafts, 16 of which were successfully revised. At 3 years, cumulative primary and secondary patency rates were 60% and 69%, respectively. Factors correlating with increased secondary patency were intraoperative flow rate > or = 50 mL/min (P = 0.004) and diabetes (P < 0.05). Major amputations were performed on 17 limbs. The cumulative foot salvage rate at 3 years was 79%. CONCLUSION: Pedal bypass is a safe, effective, and durable procedure. It should be considered even for high-risk patients with critical limb ischemia before major amputation is contemplated.

Cutaneous laser Doppler flowmetry: applications and findings.

OBJECTIVE: To examine the historical development, evolution, strengths and weaknesses, and applications (current and future) of laser Doppler flowmetry (LDF). DESIGN: A review and summary of the literature on the cutaneous uses and successful applications of LDF are presented as well as a brief discussion of the noncutaneous and nonvascular applications. MATERIAL AND METHODS: LDF measures Doppler-shifted quantities of reflected laser light at a superficial level to determine cutaneous and noncutaneous microcirculatory flux of erythrocytes. LDF is non-invasive and inexpensive. RESULTS: This relatively recent technologic development has shown considerable potential as a tool for evaluating the cutaneous circulation. Although early studies suggested that LDF had substantial difficulties with sampling, stability, and reproducibility, subsequent refinements in equipment and application have led to technical acceptability. CONCLUSION: LDF seems to be particularly valuable for assessing the microcirculation and real-time changes in skin blood flow. It has been used successfully in many investigations of the cutaneous and noncutaneous blood flow in patients with fixed or vasospastic vascular disorders, neuropathies, tumors, or ulcers as well as those who have undergone intestinal, orthopedic, or plastic surgical procedures.

Compliance changes in venous insufficiency.

In 37 patients (69 limbs) referred to Mayo Clinic's Vascular Center for possible venous valvular insufficiency in the lower limb, calf muscle pump function, calf compliance, and venous refilling times were measured by strain gauge plethysmography techniques. Patient limbs were separated into four categories based on 90% refilling time (T90) following fifteen deep knee bends: normal (n = 16), mild/moderate (n = 28), severe (n = 16), and edema of nonvenous origin (n = 9). Pump function was assessed in actual pumping volumes (mL) and in percent pumping volumes (mL/100 mL), and was reduced in all noncontrol categories. Calf compliance was assessed in actual volume change (mL/mmHg) and in percent volume change (mL/100 mL/mmHg) and was increased in the severe reflux category. Ten study patients had 1 normal category limb and 1 reflux category limb. Paired analysis of these limbs showed pump function to be decreased and calf compliance to be increased in the diseased group limbs.