A New Modified Surgical Technique of In Situ Reverse Arterialization: Leaving the Distal Saphenous Side Branches Open of Nonreconstructable Ischemic Leg Leads to Full Recovery.

BACKGROUND: Arterialization of the foot veins in patients with ischemic foot usually result in excessive foot edema, wound infection, venous gangrene, long hospitalization duration, and a high rate of amputation. We herein present an improved method of foot revascularization via the superficial venous system by in situ reverse arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open. METHODS: A 69-year-old patient with toe wet gangrene and end-stage peripheral vascular disease with absence of foot target arteries underwent ISRA procedure, using the great saphenous vein, which was anastomosed end-to-side to the proximal superficial femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins. RESULTS: Postoperatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Methoxyisobutylisonitrile scan conducted 4 weeks postoperatively demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the transmetatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks postoperatively. During 1,000 days of follow-up postsurgery, the flow was reduced and the transcutaneous pO2 level of the foot increased up to 76 mm Hg. CONCLUSIONS: This new modified surgical technique of ISRA, in which only proximal saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of transcutaneous pO2 and reduced flow, leading to full recovery of the ischemic foot.

Epithelioid hemangioendothelioma as a rare cause of blue toe syndrome.

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

A simplified approach to the management of gastric residual volumes in critically ill mechanically ventilated patients: a pilot prospective cohort study.

BACKGROUND: Enteral nutrition in the critically ill patient is often complicated by gastrointestinal intolerance, manifested by a large gastric residual volume. The frequency of GRV assessment and the intolerant level above which feeding is stopped is controversial. OBJECTIVES: To evaluate a novel approach to EN by allowing high GRV and once-daily assessment that was correlated with the paracetamol absorption test. METHODS: We conducted a pilot prospective study in an 18 bed general intensive care unit. The study group comprised 52 consecutive critically ill mechanically ventilated patients. Enteral nutrition was started at full delivery rate. Once-daily assessment of GRV with three consecutively repeated threshold volumes of 500 ml was performed before stopping EN. The paracetamol absorption test was performed and correlated to GRV. Patients were divided into two groups: low GRV (< 500 ml) and high GRV (at least one measurement of GRV > 500 ml). Clinical outcome included maximal calories delivered, incidence of pneumonia, ICU length of stay, and ICU and hospital mortality. RESULTS: There were 4 patients (9.5%) with ventilator-associated pneumonia in the low GRV group and 3 (30%) in the high GRV group (P = 0.12). GRV was inversely correlated to paracetamol absorption; however, neither GRV nor paracetamol absorption was associated with the development of pneumonia. Both groups had similar ICU length of stay (11.0 +/- 8.2 vs. 13.8 +/- 14.4 days, P = 0.41), and similar ICU (21% vs. 40%, P = 0.24) and hospital mortality (35% vs. 40%, P = 1.0). CONCLUSIONS: In critically ill mechanically ventilated patients, allowing larger gastric residual volumes, measured once daily, enables enteral feeding with fewer interruptions which results in high calorie intake without significant complications or side effects.

Usefulness of lipoprotein changes during acute coronary syndromes for predicting postdischarge lipoprotein levels.

The aim of our study was to evaluate the lipoprotein changes that occur during acute coronary events, and to determine the lipoprotein threshold levels that identify patients who require future statin therapy. Lipoprotein levels were measured at admission, at 6 hours, the morning after admission, before discharge, and 3 months after discharge in patients with myocardial infarction and unstable angina. Patients with myocardial infarction on thrombolytic therapy (n = 63) and patients with unstable angina (n = 33) had a decrease in low-density lipoprotein (LDL) cholesterol levels < or = 24 hours after admission (-12 +/- 20% and -6 +/- 23%, respectively), but these levels returned to baseline before discharge. In patients with myocardial infarction who did not receive thrombolytic therapy (n = 37), the decrease was more gradual and peaked before hospital discharge (-7 +/- 19%). There was good correlation between LDL cholesterol levels at admission and after discharge, especially in normotriglyceridemic patients. Over 90% of patients with LDL cholesterol > or = 125 mg/dl on the morning after admission were candidates for statin therapy after discharge. Thus, the need for future statin therapy can be predicted with fair reliability during the initial 24 hours after admission. However, elevated baseline triglyceride levels significantly affect these LDL cholesterol changes and complicate prediction of long-term lipoprotein levels.