Atypical leg ulcers after sclerotherapy for treatment of varicose veins: Case reports and literature review.

INTRODUCTION: Skin necrosis is a rare complication of foam sclerotherapy, a common form of treatment for varicose veins. PRESENTATION OF CASE: Both patients presented to the outpatient clinic within 2-14days after foam sclerotherapy with Aethoxysklerol(®) 1%, with severe soft tissue and skin necrosis. Further aggressive treatment of the ulcer was required to resolve the necrosis, resulting in marked residual scar and well granulated leg ulcer respectively. DISCUSSION: Foam sclerotherapy is a common and usually well-tolerated treatment modality for varicose veins. The aetiology of skin necrosis is conventionally related to extravasation of sclerosant. In order to minimise the risk of necrosis, the lowest concentration and lowest volume of sclerosant necessary to achieve adequate treatment of the target vein should be used. CONCLUSION: We would like to emphasise that whilst skin and soft tissue necrosis is a rare complication of foam sclerotherapy, it is a complication that is highly disfiguring and requires aggressive treatment. As such, it should be adequately discussed with the patient prior to obtaining informed consent.

eHealth in Wound Care: from conception to implementation.

Executive summary Purpose This document aims to provide wound care clinicians with a rapid and structured overview of the key issues related to use of eHealth applications (telemedicine and telehealth) within wound care. This includes: An overview of terminology and available literature Guidance on the methodology for evaluation of eHealth solutions An introduction to and discussion of the potential benefits of eHealth technologies in wound care, and the possible barriers to their implementation Recommendations for ensuring a good implementation process and supporting involvement of wound care professionals in safeguarding that eHealth solutions meet the needs of the patients. Methodology The document sections lean on the structure and focus areas of the Model for ASsessment of Telemedicine (MAST) which defines crucial items to evaluate an eHealth application. The content of the document is developed on the basis of a literature review, identifying available documentation for use of eHealth solutions in wound care. Furthermore, it draws on various key documents recently published on the general development, evaluation and implementation of eHealth solutions. These include valuable up-to-date information relevant for any group of clinicians wishing to follow and influence the way eHealth solutions are integrated into clinical practice. Findings and conclusions The literature review revealed that the amount and level of evidence for use of eHealth applications in wound care is still limited. Some MAST domains are not examined in any of the available studies. Thus, more research is required to identify the potential benefits and harms to patients, and the possible challenges related to implementation of eHealth solutions in wound care. Potential barriers and facilitators for the implementation of eHealth applications into wound care practice are identified in the document, and these may all either enhance or impede the process. However, the available research does demonstrate patient satisfaction, improved access to health services for all client cohorts, and increased job satisfaction for clinicians. The document recommends that wound management clinicians, considering the use of eHealth applications in their clinical practice, consult widely and conduct regular evaluation of the outcomes to ensure efficient implementation of these services. To support this approach, steps to ensure a good implementation process within a given organisation have been proposed. These are synthesised into a three circle model.

Stent outcomes for infrapopliteal arterial occlusive disease.

This study aimed to determine if the different stent types used in the treatment of infrapopliteal arterial occlusive disease provide any significant advantage over one another at 6 and 12-month follow-up. Consecutive patients undergoing stenting of infrapopliteal lesions were enrolled into a non-randomised prospective registry and followed-up for 1 year. Outcome measures included binary restenosis, target lesion revascularisation, major amputation, and change in Rutherford-Becker score and ankle-brachial index (ABI).Thirty-three patients were enrolled including four patients with bilateral disease. There were 20 target vessels in the drug-eluting stent (DES) group, 13 target vessels in the balloon-expandable bare metal stent (BE-BMS) group and 14 target vessels in the self expandableb are metal stent (SE-BMS) group. Most of the patients in the study were octogenarians except in the SE-BMS group where the mean age was 73 ± 9 years. At 12 months, seven patients had died (DES = 6, BE-BMS = 1) from cardiac and cancer-related diseases. In-stent and peri-stent binary restenosis were non-statistically different between all three groups. There was a nonstatistically significant trend towards higher target vessel revascularisation in the BE-BMS group. Survival curves in all stent types demonstrated restenosis to occur within the first 6 months post-procedure. There was no significant difference in the change in Rutherford-Becker score or ABI between the groups. No major limb amputations occurred during the 12-month period. In conclusion,we did not detect a significant difference in stent performance between the different stent types used to treat infrapopliteal arterial occlusive disease. The choice of stent did not seem to affect patient survival or major amputation-free survival at 1-year follow-up.

The clinical efficacy of two semi-quantitative wound-swabbing techniques in identifying the causative organism(s) in infected cutaneous wounds.

A prospective randomised controlled trial of two paired wound-swabbing techniques (Levine versus Z) was conducted to establish which method was more effective in determining the presence of bacteria in clinically infected wounds. The Levine technique involves rotating the wound swab over a 1-cm(2) area of the wound; the Z technique involves rotating the swab between the fingers in a zigzag fashion across the wound without touching the wound edge. Fifty patients were recruited into the study with acute (42%) and chronic wounds (58%). Overall, the Levine technique detected significantly more organisms than the Z technique (P≤ 0· 001). When acute and chronic wounds were analysed separately, the Levine technique again detected more organisms in both acute (P≤ 0· 001) and chronic wounds (P≤ 0· 001). We conclude that the Levine technique is superior to the Z technique and this result may be because of the Levine technique's ability to express fluid from the wound bed and thereby sampling a greater concentration of microorganisms from both the surface and slightly below the surface of the wound.

Open endarterectomy of the SPT segment: an experience.

The purpose of the study was to evaluate the results of open endarterectomy in short atherosclerotic occlusions of the SPT segment (superficial femoral, popliteal, and tibioperoneal arteries). Retrospectively, records from July 1999 to June 2004 of patients who underwent open endarterectomy of lower limb arteries were verified; 63 patients with 66 lesions had open endarterectomy of the SPT segment as a primary procedure. At the time of this study, there were 57 patients alive and six dead, with the cause of death being unrelated to the procedure. The patients had a mean age of 71 +/- 10.73 years, and there were 18 females and 45 males. All patients underwent routine follow-up at 1, 3, 6, and 12 months and yearly thereafter. Routine clinical examination and ultrasound were done to assess the outcome. The mean length of endarterectomized superficial femoral artery was 7.42 +/- 3.66 cm (range 2-15). The lesions involved were the superficial femoral, popliteal, and tibioperoneal arteries (SPT segment). The primary cumulative patency rate by means of life-table analysis was 48.8% at 5 years (mean 12.7 months, range 1-60). During follow-up, percutaneous transluminal angioplasty was necessary in nine patients, for a primary assisted patency rate of 85.1% at 5 years. The location of recurrent stenoses after endarterectomy was usually at one of the ends of the endarterectomy site. Once a preferred technique, endarterectomy is now overshadowed by bypass procedures. Our clinical experience suggests that, in a select group of patients with SPT segment occlusions, open endarterectomy is technically feasible and should be used in cases with insufficient vein for bypass grafting. It also can be used as an alternative to allow the long saphenous vein to be reserved for a bypass procedure in the future.

Microbiological profile of chronic ulcers of the lower limb: a prospective observational cohort study.

BACKGROUND: The aim of the study was to determine the microbiological profile of chronic lower-limb ulcers in a tertiary outpatient setting. METHODS: A prospective observational cohort study of 39 patients with lower-limb ulcers of more than 1 month duration, presenting to the leg ulcer clinic. Superficial swab and punch biopsy samples were taken from each ulcer. RESULTS: Mean age was 68.7 years. Venous ulcers were most common (51%) followed by arterial ulcers (13%), ulcers in people with diabetes having arterial disease (13%), unspecified ulcers (13%) and ulcers in people with diabetes (10%). The most common organisms were Staphylococcus aureus (38-44%) followed by Pseudomonas aeruginosa (26-28%). Biopsy and swab results were concordant in 18 (46%), had at least one organism in common in 10 (26%) and had no concordance in 11 (28%). Histological analysis did not show any cases of malignancy. Ulcer area was significantly lower after 2 months of treatment (P = 0.047). Venous ulcers had the best outcome at 2 months, whereas people with diabetes with arterial disease fared poorly. CONCLUSION: The microbiological profile of chronic leg ulcers has application to general treatment principles as well in guiding the necessity and choice of antibiotic therapy. Concordance between swab and biopsy results was poor; we recommend biopsy in the tertiary setting.

Iatrogenic entrapment: femoro-popliteal vein bypass graft.

A rare cause of occlusive vascular disease is the "Popliteal Artery Entrapment Syndrome." The most common cause of this problem is abnormal position of the popliteal artery caused by abnormal migration of the medial head of the gastrocnemius. An acquired form can occur because of tunneling defects by inadvertent placement of venous bypass graft medial to the medial head of the gastrocnemius muscle. We present 2 cases of iatrogenic entrapment of the femoropopliteal bypass graft. Investigations revealed compression of the graft with extension of the knee. Both cases were treated surgically. Intraoperatively there was evidence of compression of the graft between the tendons of the semitendinosus and the gracilis muscles and the medial head of the gastrocnemius muscle. Treatment involved division of the medial head of the gastrocnemius in 1 patient, and in the other, the tendons of gracilis and semitendinosus were divided. No compression of the graft was noted postoperatively by noninvasive test. No significant mobility issues caused by the division of muscle or the tendons were present in the postoperative period.

Outcomes of a contemporary amputation series.

BACKGROUND: The aim of this study was to determine the outcomes of a contemporary amputation series. METHODS: A retrospective audit of 87 cases of major lower limb amputation from January 2000 to December 2002 from the Department of Vascular Surgery, Royal Perth Hospital, was conducted. RESULTS: The mean age of the study population was 70.1 +/- 14.3 years; the male : female ratio was 3.35:1. Comorbid problems included diabetes (49.4%), smoking (81.6%), hypertension (77.0%), ischaemic heart disease (58.6%), stroke (25.3%), raised creatinine level (34.5%) and chronic airway limitation (25.3%). Preamputation vascular reconstructive procedures were common, 34.5% in a previous admission and 23.0% in the same admission. The main indication was critical limb ischaemia (75.9%) followed by diabetic infection (17.2%). There were 51 below-knee (58.6%), 5 through-knee (5.7%) and 31 above-knee (35.6%.) amputations. The below-knee amputation to above-knee amputation ratio was 1.65:1. The overall wound infection rate was 26.4%; the infection rates for below-knee (29.4%) and above-knee (22.6%) amputation did not differ significantly (P = 0.58). Revision rates were 17.6% for below-knee, 20% for through-knee and none for above-knee amputations. Twenty patients (23.0%) underwent subsequent contralateral amputation. Thirty-nine patients (44.8%) were selected as suitable for a prosthesis by a rehabilitation physician; 31 (79.5%) used the prosthesis both indoors and outdoors and 6 (15.4%) used it indoors only within 3 months. Cumulative mortality at 30 days, 6 months, 12 months and 24 months was 10.1, 28.7, 43.1 and 51.7%, respectively. CONCLUSION: This series agrees with the current published work in finding that patients undergoing major lower limb amputation are older, with a high prevalence of comorbid conditions. Successful prosthesis rehabilitation depends on patient selection and a multidisciplinary approach. Despite a low immediate mortality, the overall long-term results of lower limb amputation remain dismal.

Comparison of short-term clinical postoperative outcomes in patients who underwent carotid endarterectomy: intensive care unit versus the ward high-dependency unit.

The objective of this research was to examine the routine postoperative management of patients who have undergone carotid endarterectomy and compare the intensive care unit (ICU) with the ward high-dependency unit (HDU) in terms of the number, type, severity, or management of postoperative clinical events within a 48-hour time frame. Two of the vascular surgeons routinely admitted patients to the ICU, and 1 vascular surgeon routinely admitted patients to the ward HDU. This research determines whether there was a difference in outcomes between the 2 groups with the intention of changing the practice of the 2 vascular surgeons who routinely admitted their patients to the ICU. This was a nonexperimental, descriptive, prospective study of all patients who underwent carotid endarterectomy during an 18-month period between August 1999 and January 2000. A total of 104 patients were recruited to the study. There were 84 patients in the ICU cohort; 59 were male and 25 were female, with a mean age of 72 years. There were 20 patients in the ward HDU cohort; 12 were male and 8 were female, with a mean age of 66 years. Major complications occurred in 3 patients. One patient from the ICU group was returned to the operating room for evacuation of a hematoma, and 2 patients from the ward HDU group were transferred to the ICU for an inotropic infusion. During the first 24 hours, hypertension developed in 37 patients in the ICU cohort, 12 of whom did not require intervention. Hypertension requiring intervention developed in 3 patients in the ward group. Chi-square cross-tabulation revealed a chi 2 value of 1.4 and a P value of.01, which is a significant difference in the number of hypertensive events in the ICU versus the ward HDU. Hypotension occurred in 41 patients in the ICU group and in 9 patients in the ward cohort. The same chi 2 test was used to reveal a chi 2 value of 0.026 and a P value of.87, which are nonsignificant results. There was no difference in the number of hypotensive events in the ICU versus the ward HDU. There were no reported incidents of tachycardia. Bradycardia was reported in 64 patients in the ICU group and in 12 patients in the HDU group. There was no significant difference in the number of patients with bradycardia in either group of patients. Chi-square analysis revealed a chi 2 value of 1.4 and a P value of.23 during the first 24 hours postoperatively. We believe that careful selection of patients to the ward HDU is safe and cost-effective.