Value of drug-eluting stents after failed percutaneous transluminal angioplasty in the infrapopliteal vessels for the treatment of critical limb ischemia: favorable mid-term patency and limb salvage results.

AIM: The endovascular treatment of infrapopliteal arterial disease in the setting of critical limb ischemia (CLI) is increasing in use. In patients in whom percutaneous transluminal angioplasty (PTA) resulted in suboptimal angiographic results, flow limiting dissection or re-coil is thought to limit clinical success. This single-center experience examines the angiographic and clinical results when Drug-Eluting Stents (DES) were placed in a large cohort of patients with CLI after immediate infrapopliteal PTA failure. METHODS: A retrospective review of a prospectively collected single-center endovascular database was performed. Sixty-seven Rutherford grade 4, 5, and 6 patients were treated between October 2005 and February 2010 with PTA because lack of an acceptable autologous vein for bypass-grafting or severe medical comorbidities precluded them from surgical bypass. The study cohort had suboptimal angiographic results immediately after PTA that was subsequently treated with DES. Patients were then placed on clopidogrel and aspirin indefinitely. Angiographic, clinical, and the results of noninvasive vascular examinations were collected. RESULTS: In total, 123 stents (94 sirolimus, 27 everolimus, 2 paclitaxel) were placed in 67 patients to treat a total of 84 angiographic lesions. Simultaneous femoral-popliteal intervention was performed in 66% of the patients while 45% of the treated lesions were total occlusions. Lesion length ranged from 17 mm-142 mm (mean 50 mm). Initial technical success was 100%, with all 84 lesions being treated successfully with less than 10% stenosis after stent implantation. Mean follow-up was 20 months (1-42 months) with 6, 12, and 24-month primary patency rates of 90%, 86%, and 72% respectively. Freedom from major amputation was 91.1% (61/67) with all six amputations occurring in the Rutherford grade 6 group (6/11). Overall mortality rate was 19% (13/67) with one death occurring within 30 days. CONCLUSION: The use of drug-eluting stents following suboptimal PTA for the treatment of infrapopliteal arterial disease in this cohort of patients with CLI produced high primary patency and limb salvage rates supporting the efficacy of this treatment strategy.

Antiretroviral-induced hepatic steatosis and lactic acidosis: case report and review of the literature.

As the prevalence of human immunodeficiency virus (HIV) infection continues to rise the clinician is encountered with a diagnostic challenge. Nonsurgical diseases such as acute colitis or enteritis can appear similar to such true surgical emergencies as abscess, perforation, or mesenteric ischemia. We report a case of fulminant hepatic failure associated with didanosine and masquerading as a surgical abdomen and compare the clinical, biologic, histologic, and ultrastructural findings with reports described previously. This entity should be kept in mind when evaluating the acute abdomen in the HIV-positive patient.

A retrospective study of diagnosis and management of mesenteric vein thrombosis.

BACKGROUND: Mesenteric vein thrombosis (MVT) is an uncommon type of intestinal ischemia associated with significant mortality and morbidity because of its delay in diagnosis. METHODS: A retrospective analysis of 9 patients treated surgically for MVT during 1982 to 1997 was performed. RESULTS: Nine patients underwent surgical therapy for intestinal ischemia due to MVT. The most common presenting symptom was abdominal pain with bloody diarrhea in 3 patients; preoperative diagnosis of MVT was suspected in 2. Radiologic tests included plain roentgenograms, computed axial tomography, and ultrasound. Time to surgery ranged from 3 hours to 7 days after admission. All patients underwent resection of infarcted bowel with primary anastomosis and immediate postoperative anticoagulation. No patient underwent a second-look operation. The postoperative morbidity and mortality rates were 55% and 11%, respectively. CONCLUSION: Diagnosis of intestinal ischemia from MVT is often delayed, and strong clinical suspicion and aggressive treatment are necessary in its management.

Does clinical exposure affect medical student examination performance?

BACKGROUND: Traditionally important components of the surgical clerkship curriculum include lectures, small-group sessions, readings, clinical exposure, and testing. Time constraints require compromise among all these elements. At our institution, clinical exposure of medical students varies according to their team assignments. They differ primarily in exposure to such topics as trauma, inflammatory bowel disease (IBD), and vascular surgery. PURPOSE: The goal of this study was to quantify the influence of clinical exposure on medical student education, testing whether it influences examination performance. METHODS: At the beginning of the clerkship, students were given a written multiple-choice examination covering these three topics. They completed two 4-week blocks on surgery services in various settings. At the end of the clerkship, they were reexamined. Differences between pretest and posttest overall mean rank were analyzed using the Wilcoxon signed ranks test. Differences in improvement based on clinical exposure were analyzed using the Mann-Whitney U test. RESULTS: Statistically significant improvement was seen in overall examination performance, as well as in each of the subsections. However, these improvements could not be accounted for by clinical exposure. There was no statistically significant difference in mean rank in improvement based on clinical exposure to vascular, IBD, or trauma. CONCLUSIONS: Student examination scores improved over the course of the clerkship. No improvement could be attributed to greater clinical exposure to a topic.