Stenting complex aorta aneurysms with the Cardiatis multilayer flow modulator: first impressions.

OBJECTIVES: Our aim was to assess the feasibility and efficacy of the Cardiatis multilayer flow modulator in the treatment of complex aorta aneurysms. METHODS: This is a single-center prospective registry. Six patients (4 males and 2 females; mean age 74 years) with complex aorta aneurysms (unsuitable for endovascular repair with standard, fenestrated, or branched stent grafts) were treated with the Cardiatis multilayer flow modulator. RESULTS: Clinical success was 100%. Median follow-up was 10 months. One patient died the third postoperative day due to aneurysm rupture. Four aneurysms were completely thrombosed between 1 and 6 months after the procedure. The patency of the covered aortic branches was 100%. At 6 months, the sac volume was decreased in two patients, increased in two patients and remains stable in one patient. There were no stent migrations, retractions, thrombosis, fractures, or reinterventions. CONCLUSIONS: The device preserves flow into the covered aortic branches and completed aneurysm thrombosis occurs gradually; however, the stent did not prevent rupture immediately after the implantation. Longer follow-up is mandatory to prove the efficacy of this technology.

Gas gangrene in the diabetic foot: lessons learned from a salvaged limb.

A 55 year old man was seen in the emergency department with an infected right foot and sepsis. Examination of the right foot revealed subcutaneous crepitus from the metatarsal head up to the tarsus; interstitial and intramedullary gas was confirmed on x-rays and computed tomographic scans. During 44 days of hospitalization, the patient was treated with multiple courses of antibiotic therapy, various wound care modalities (including negative wound pressure therapy) and several surgical interventions (debridements, amputations, revascularizations and reconstructive plastic surgery). Although limb salvage was ultimately accomplished, in retrospect many management decisions were suboptimal. A critical reassessment of our approach to this patient allowed us to identify several areas for improvement and this audit provided us an opportunity to learn from managing this difficult case.

Fighting human error : what surgeons can learn from aviators.

BACKGROUND: The rigorous implementation of safety policies have made air travel one of the safest modes of transport. Health institutions and hospital managing bodies increasingly adopt cues from aviation safety protocols and policies in an attempt to reduce medical errors and patient harm. Among hospital staff, surgeons are most likely to be confronted with these aviation-derived safety concepts. METHODS: This article aims to familiarize surgeons with the concepts and methodology of safety policies in modern aviation safety, many of which have been applied in the setting of surgery, or have potential to do so. We review the use of checklists, crew resource management, the sterile cockpit, blame free reporting and human fatigue. We discuss how these concepts can be translated to the operating room and illustrate their relevance through a comparative description of historical air accidents and surgical incidents from our own clinical experience. We also indicate relevant differences and similarities between flight crews and surgical teams and their respective infrastructures, as these may impede or facilitate the adoption of aviation safety policies. Finally, we offer some recommendations to effectively implement aviation safety policies in the operating room.

Skin grafting the contaminated wound bed: reassessing the role of the preoperative swab.

OBJECTIVE: To investigate use of the preoperative wound swab to predict graft failure compared with establishing the indication for skin grafting on clinical grounds alone. METHOD: Patients requiring meshed split-thickness skin grafting were prospectively included; the indication for grafting was established on clinical grounds exclusively. A preoperative swab of the wound bed was taken, but its result was concealed to prevent it influencing clinical decision-making. Negative pressure wound therapy (NPWT) was used for both wound bed preparation and graft fixation.After 2 months, graft area take percentage was measured using digital image processing software and the results validated against the result of the preoperative wound swab. RESULTS: Eighty-seven wounds were included in the study. Mean graft area take percentage was 88%,with five grafts considered complete failures(< 25% take).A posteriori analysis of the wound cultures showed that 53% had been contaminated on grafting, but these did not fare any worse than near-sterile wounds. Qualitative analysis of cultures showed that wounds containing either Pseudomonas aeruginosa or Staphylococcus aureus did have inferior outcome (mean take percentage 78.9% vs 91.3%; p=0.038).Diabetes was also a deteriorating factor (mean take percentage 83.0% vs 90.7%; p=0.004). CONCLUSION: Establishing the indication for skin grafting on clinical grounds exclusively does not yield grossly inferior results. In light of recent advances in skin grafting, including use of NPWT as adjuvant therapy, the requirement for routine preoperative wound swabs may be questioned.

The surgical history of the amputated limb according to the indication for revascularization: diabetic foot, acute ischaemia, aneurysmal disease, chronic arterial occlusive disease.

BACKGROUND: To investigate whether the indication for the first revascularization (diabetic foot, acute ischaemia, aneurysmal disease, chronic occlusive disease) determines the surgical history and survival time in amputated limbs. METHODS: The surgical history of lower extremities amputated between 2002 and 2009 was reviewed for the number of (endo)vascular procedures, minor amputations, wound debridements, complications requiring surgery (acute ischaemia, bleeding, graft infection) and limb survival time (LST). RESULTS: 100 limbs were included in the study. The four groups underwent a similar number of surgical procedures (mean 4.1). Diabetic foot limbs had fewer revascularizations (mean 1.3, p = 0.003) and complications (mean 0.1, p = 0.005), but more minor amputations and wound debridements (mean 1.3, p = 0.002), in a significantly shorter LST (mean 555 days, p = 0.003). Acute ischaemic limbs showed the shortest LST (mean 179 days, p = 0.003) and significantly more complications (mean 0.8, p = 0.005). Limbs initially treated for aneurysmal disease or chronic occlusive disease had the highest number of revascularizations (mean resp. 2.7 and 2.6) and the longest LST (mean resp. 1669 and 1459 days, p = 0.001). Limbs with advanced chronic occlusive disease (rest pain or gangrene) presented with fewer revascularisations (mean resp. 2.5 and 1.8, p = 0.01) and a shorter LST (mean resp. 1284 and 794 days, p = 0.004) compared to claudicants. CONCLUSIONS: Our study suggests that the surgical history and limb survival in amputated limbs is disease and stage specific, and determined by the indication of the first revascularisation.

Isotopic dating of strain fringe increments: duration and rates of deformation in shear zones

The time scales over which deformation in the Earth's crust remains localized in shear zones are poorly known, as are the associated strain rates. We have determined the longevity and rates of deformation using rubidium-strontium (Rb-Sr) microsampling dating of increments of fibrous strain fringes from a Pyrenean shear zone. The fibers grew quasi-continuously through a protracted deformation history between 87 and 50 million years ago, over a period comparable to that of an orogeny. During a short interval between 66 and 62 million years, a rise in strain rate from 1.1 x 10(-15) to 7. 7 x 10(-15) seconds(-1) occurred. This acceleration correlates with an abrupt change in fiber-growth direction and a stress-field inversion from gravitational collapse to renewed horizontal crustal shortening.