Wound morphology and topography in the diabetic foot: hurdles in implementing angiosome-guided revascularization.

Purpose. Angiosome-guided revascularization is an approach that improves wound healing but requires a surgeon to determine which angiosomes are ischemic. This process can be more difficult than anticipated because diabetic foot (DF) wounds vary greatly in quantity, morphology, and topography. This paper explores to what extent the heterogeneous presentation of DF wounds impedes development of a proper revascularization strategy. Methods. Data was retrieved from a registry of patients scheduled for below-the-knee (BTK) revascularization. Photographs of the foot and historic benchmark diagrams were used to assign wounds to their respective angiosomes. Results. In 185 limbs we detected 345 wounds. Toe wounds (53.9%) could not be designated to a specific angiosome due to dual blood supply. Ambiguity in wound stratification into angiosomes was highest at the heel, achilles tendon, and lateral/medial side of the foot and lowest for malleolar wounds. In 18.4% of the DF, at least some wounds could not confidently be categorized. Proximal wounds (coinciding with toe wounds) further steered revascularization strategy in 63.6%. Multiple wounds required multiple BTK revascularization in 8.6%. Conclusion. The heterogeneous presentation in diabetic foot wounds hampers unambiguous identification of ischemic angiosomes, and as such diminishes the capacity of the angiosome model to optimize revascularization strategy.

Discharge on the first postoperative day after elective carotid endarterectomy.

BACKGROUND: Medical complications may prolong the hospital stay after elective carotid endarterectomy (CEA). We prospectively assessed the social and medical feasibility and safety of patient discharge on the first postoperative day after elective CEA and unplanned readmissions. METHODS: Between June 2011 and January 2012, 57 consecutive patients scheduled for elective CEA were enrolled with the aim of discharge on the first postoperative day if there were no medical contraindications and on the condition that the patient should not be left alone during the first day and night at home. CEA was carried out under local or general anesthesia. After discharge, the patients were contacted to ascertain the occurrence of arterial hypertension, cerebral hyperperfusion, focal cerebral ischemia, or hospital readmission. RESULTS: Sixty-two CEA were carried out in 57 patients (33 men and 24 women ranging in age from 51-89 years). The indications for CEA were: asymptomatic high grade stenosis in 27, hemispheric transient ischemic attack in 12, amaurosis fugax in 6, recovered stroke in 16, and nonlateralizing signs in 1. There were no cases of perioperative stroke or death. Discharge on the first postoperative day was achieved in 45 cases (73%). In 15 cases (24%), discharge was on the second postoperative day because of the absence of a relative (12 cases) or for medical reasons (3 cases). Discharge was on day 3 in 1 case, and on day 10 in another, both for medical reasons. No cases of severe arterial hypertension, stroke, mortality, or readmission for reasons related to the CEA procedure were recorded up to postoperative day 30. CONCLUSION: In this study, the majority of patients undergoing elective CEA were discharged safely on the first postoperative day. Social reasons, rather than medical reasons, underlied most cases of later discharge. There were no unplanned readmissions for complications of CEA.

Intraluminal crossing of near-impenetrable occlusions by balloon-assisted battering ram technique.

PURPOSE: Subintimal crossing of total occlusions and acquiring reentry into the true lumen may be hazardous in highly calcified lesions, with or without the use of expensive reentry devices. Even when desirable, intraluminal crossing may not be feasible, because the guidewire tends to follow a path of least resistance between the intimal plaque and the adventitia. TECHNIQUE: A standard percutaneous transluminal angioplasty balloon is positioned just above the proximal cap of the occlusion and insufflated to 6 atmosphere. The balloon is used (1) to increase guidewire support close to the lesion and (2) for centralization purposes (limiting lateral movement of the guidewire). The ultra stiff back end of a regular guidewire can then be used to target the center of the cap while repeatedly pounding against it until it breaches. CONCLUSIONS: The balloon-assisted battering ram technique may be attempted if intraluminal crossing is warranted before resorting to other complicated, expensive devices.

Treatment of lymphocutaneous fistulas after vascular procedures of the lower limb: accurate wound reclosure and 3 weeks of consistent and continuing drainage.

BACKGROUND: Lymphocutaneous fistulas occurring after vascular procedures of the lower limb are a rare, but frustrating, complication. Many treatment options exist, but may lead to inconsistent results, with infection, delayed wound healing, and prolonged hospital stay. We present a simple surgical treatment of wound closure and drainage. METHODS: In this single-center, single-intervention, observational clinical study (case series), prospectively collected data of 23 consecutive lymphocutaneous fistulas in 22 patients (19 male and three female; age, 42 to 91 years) treated between June 2005 and October 2008 were retrospectively analyzed. Twenty-two fistulas were situated in the groin and one at the knee incision. The standardized therapy consisted of the installation of a Redon to drain the lymph, and accurate closure of the wound. Postoperatively, drainage was maintained for 21 days: suction Redon drainage for the first 7 days, passive Redon drainage for the next 7 days, and further drainage in a pouch after removal of the drain for the last 7 days. RESULTS: In 19 of the initial 23 lymphocutaneous fistulas, the whole drainage procedure was completed, with healing of the wound, without infection, recurrence, or lymphocele formation after 1 year of follow-up. In these cases, there had been a steady decrease of daily lymph drainage: a mean of 163.4 (standard error on the mean, 39.6) mL on the first day of suction, 56.8 (15.5) mL on the first day of passive drainage, 11.6 (4.3) mL on the last day of passive drainage, and 2.1 (0.9) mL on the 21st day when the drainage treatment was stopped. In four fistulas, this treatment was considered a failure because of inadvertent early drain removal (two cases), infection (one case), and lymphorrhea recurrence with wound breakdown (one case). CONCLUSION: This standardized surgical therapy, consisting of accurate wound closure and 3 weeks of drainage, allowed the healing of 19 of 23 postoperative lymphocutaneous fistulas (an 82.6 % success rate), without infection, recurrence, or lymphocele formation after 1 year of follow up.

Primary closure with a filleted hallux flap after transmetatarsal amputation of the big toe for osteomyelitis in the diabetic foot: a short series of four cases.

In the diabetic foot, osteomyelitis of the first metatarsal head adjacent to a malum perforans may require resection of the metatarsophalangeal joint. This results in a dysfunctional great toe and large tissue defects that take a long time to heal. The authors postulated that transmetatarsal amputation followed by primary closure with a filleted hallux flap would be feasible in selected cases. Patients that required surgery for diffuse bone destruction of the first metatarsal head were included in the study. Transmetatarsal amputation was performed only if tissue removal rendered the hallux functionless. Primary closure with a filleted hallux flap was attempted in four out of sixteen patients. The developed skin flaps invariably were long enough to cover the plantar tissue defect; no flap necrosis or recurrent infection was noted. Mean healing time was 44 days (range 9-69). Long-term results were disappointing due to ulcer recurrences under the remaining metatarsal heads.

Establishing the learning curve for a tunneled dialysis catheter placement.

PURPOSE: To determine how many procedures a surgical trainee requires before they are able to place a tunneled double-lumen dialysis catheter safely on their own. METHODS: Surgical trainees unfamiliar with the procedure received a pre-operative briefing in which we explained 1) why, how, and in what particular order each operational step should be executed and 2) what the possible pitfalls/complications are. Next, an experienced surgeon demonstrated the procedure with the trainee scrubbed-in as their assistant. The trainee then performed all successive procedures, while the supervising surgeon acted as a silent observer and intervened only when an error was made. We recorded all errors as well as near misses and noted if they were severe, recurrent or unanticipated. At least three procedures were required but training was continued until less than three errors were made. RESULTS: Ten trainees were included in the study. On average, a trainee made 11.9 mistakes during 3.4 procedures in a time span of 28.2 days. Only three trainees performed their last procedure flawlessly. The number of errors decreased exponentially from the first procedure onwards (P<.001). A statistically significant correlation was found between the number of mistakes and the number of days since the last procedure (P<.035). Unanticipated errors most frequently involved erroneous fluoroscopy interpretation, flushing with blood-contaminated saline, and incorrect volume injection for the heparin lock. CONCLUSIONS: A theoretically well-prepared surgical trainee should be able to perform the placement of a tunneled dialysis catheter safely after four procedures. Training is more efficient when procedures follow each other quickly.

The ankle--brachial index and the diabetic foot: a troublesome marriage.

BACKGROUND: The ankle--brachial index (ABI) is a simple, noninvasive, widely used test that detects peripheral arterial disease (PAD). In patients with diabetes, the ABI is notoriously unreliable and this is usually attributed to medial calcinosis, which stiffens the arteries and renders them poorly compressible. However, the distribution of atherosclerotic lesions in those with diabetes is different as well: lesions predominantly reside in below-the-knee (BTK) arteries. To what extent this contributes to the unreliability of the ABI is unknown. The aims of this study were (1) to confirm the notion that the ABI poorly predicts PAD in the diabetic foot, (2) to determine whether arterial calcifications can be blamed, and (3) to establish the role of the distribution of atherosclerotic lesions. METHODS: We studied 187 lower extremities with a diabetic foot that had an intra-arterial angiography and an ABI. The extent of atherosclerosis on angiography was rated by scoring all arterial segments from the aorta to the foot conforming to the Joint Vascular Societies reporting standard. Arterial calcification was assessed using a 4-level severity scale based on the number and length of calcified arterial segments as seen on plain X-ray. The ABI was calculated using four arterial pressures (two brachial, dorsal pedal, and tibial posterior arteries). To prove that the standard ABI is ill-designed to detect atherosclerosis located in BTK arteries, we postulated that an ABI that incorporated more information about these arteries would correlate better with angiographic atherosclerotic disease. To this end, we compared the standard ABI (which only uses the highest distal pressure available and neglects the pressure in other BTK arteries) with two alternatively calculated ABIs: one using the lowest pressure as numerator, and one with the average of both pressures while assuming a pressure of 0 for arteries that were not found by Doppler. RESULTS: The ABI could be determined in 123 cases (65.7%), mean ABI was 0.92. Analysis of the angiographies showed that atherosclerotic lesions had a high predilection for BTK arteries. The correlation between ABI and angiographic PAD was weak (Pearson correlation coefficient r = -0.487). Arterial calcification was absent in 36.9%, and considered to be light (5.4%), moderate (17.1%), or heavy (40.6%). Patients with moderate or heavy calcifications were grouped together and considered to have calcified arteries. These individuals had a lower ABI (p < 0.013), more advanced atherosclerotic disease (p < 0.001), and a higher interbrachial pressure differential (p < 0.017). Of all the ABIs tested, the one that used both distal pressures correlated best (r = -0.554) with atherosclerotic disease. Irrespective of how the ABI was calculated, patients without calcifications consistently had a better correlation with atherosclerotic disease than those with calcified arteries. CONCLUSION: The ABI underestimated angiographic atherosclerotic disease in this population of patients that we thought had PAD causing tissue loss. Calcifications were frequently present and indeed can be partly blamed for the unreliability of the ABI, but the distribution of atherosclerotic disease can be held responsible as well: the ABI is hampered by design because it is meant to detect a drop in pressure caused by the additive effect of serially located lesions in the arterial tree. In the diabetic foot, where lesions tend to be situated in BTK arteries (which lie parallel to each other), the pressure measured in one distal artery is less representative of atherosclerotic disease in the lower extremity.

Diabetes mellitus is a predictor for early adverse outcome after carotid endarterectomy.

PURPOSE: The aim of the study was to compare the outcome after carotid endarterectomy (CEA) in patients with and without diabetes mellitus. METHODS: We prospectively recorded the data from patients who underwent CEA. A patient was considered diabetic when he reported the use of antidiabetic medication. De novo diagnosis of diabetes was defined as the first demonstration of a fasting glucose serum concentration >126 mg/dL or >200 mg/dL after glucose load. An early adverse outcome was defined as the occurrence of ipsilateral minor or major stroke and/or death during the 30-day postoperative period. RESULTS: The stroke and death rate was significantly higher in diabetic patients (n = 380) compared to the controls (n = 971; 4.5% versus 1.5%, P = .002). Multivariate analysis showed a significant association between the presence of diabetes and 30-day stroke and death rate (OR 2.94, CI 1.46-5.97, P = .003). CONCLUSIONS: Diabetic patients are at greater risk for perioperative stroke and death.

Normalization of generalized retinal function and progression of maculopathy after cessation of therapy in a case of severe hydroxychloroquine retinopathy with 19 years follow-up.

A 40-year-old Caucasian female was first seen 20 years ago for a routine ocular screening in relation to hydroxychloroquine treatment for systemic lupus erythematosus. Her daily dose was 600 mg (or 12 mg/kg of body weight/day) of hydroxychloroquine. Three years later, she complained of mild visual loss in the right eye. Her best-corrected visual acuity was 0.9 in the right (RE) and 1.0 in the left eye (LE). In addition, she had a central scotoma (RE > LE) on automated visual field analysis (Humphrey central 30 degrees ). On fundoscopy and fluorescein angiography, the first signs of a bilateral bull's eye maculopathy were detected. A decreased Arden ratio on EOG (<1.50) was found with an accompanying decreased amplitude of the scotopic b-wave on full-field electroretinography in both eyes. Consequently, the treatment was immediately stopped. During the following years, the patient was retested regularly. After more than 18 years after cessation of the drug, most tests showed a further deterioration, including best-corrected visual acuity (RE: 0.1; LE: 0.7). On visual field testing, a progressive evolution to a total and absolute central scotoma in the RE (central 10 degrees ) and an annular scotoma in the LE became apparent. In contrast, a partial recovery of the Arden ratio of the EOG to 1.8 in both eyes was seen. In addition, a partial recovery of the scotopic b-wave full-field ERG was noted 19 years after cessation of treatment. At retest visits respectively 18, 19 and 20 years after cessation of hydroxychloroquine, a multifocal electroretinogram was performed in combination with colour vision tests and contrast sensitivity measurements.

Markers of inflammation in patients with symptomatic and asymptomatic carotid artery stenosis: a case-control study.

OBJECTIVES: There is evidence that inflammation plays a role in the pathogenesis of atherosclerosis. We compared levels of inflammatory markers between patients undergoing carotid endarterectomy (CEA) and controls, and between patients with symptomatic and asymptomatic internal carotid artery (ICA) stenosis. MATERIALS AND METHODS: A total of 180 patients with ICA stenosis were compared with 180 age-matched and sex-matched controls. The biomarkers evaluated were high-sensitivity C-reactive protein (hs-CRP), soluble intercellular adhesion molecule 1, soluble vascular cell adhesion molecule 1 (sVCAM-1), and interleukin-6 (IL-6). RESULTS: The levels of hs-CRP, sVCAM-1, and IL-6 in the CEA group were significantly higher than in the control group (1.87 mg/mL vs 1.44 mg/mL, P = .011; 1408 ng/dL vs 672 ng/dL, P < .001; 11.9 pg/mL vs 6.3 pg/mL, P < .001). Multivariate linear regression analysis, adjusted for all clinical and physiologic parameters, showed a significant association between ICA stenosis and hs-CRP, sVCAM-1, and IL-6 concentrations. Analysis of symptomatic (n = 101) and asymptomatic (n = 79) ICA stenosis did not detect a difference in levels of these markers. CONCLUSIONS: Our study suggests that inflammatory markers could serve as markers for ICA atherosclerosis but are not useful to identify carotid plaque at risk for symptomatic conversion.

Endogenous sex hormone levels in postmenopausal women undergoing carotid artery endarterectomy.

OBJECTIVE: To study the endogenous sex hormone levels in natural postmenopausal women and their association with the presence of internal carotid artery (ICA) atherosclerosis. DESIGN: Case-control study METHODS: We compared 56 patients with severe ICA atherosclerosis referred for carotid artery endarterectomy (CEA) with 56 age-matched control subjects free of severe atherosclerotic disease. The presence of atherosclerosis was determined by high-resolution B-mode ultrasound. Metabolic parameters and sex hormones were measured or calculated: total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, glucose, insulin, quantitative insulin sensitivity check index, insulin resistance index, IGF-I, DHEA, DHEA sulfate (DHEA-S), free testosterone, total testosterone, estrone, estradiol, androstenedione, and sex hormone-binding globulin. RESULTS: The cases had statistically significant lower levels of both total testosterone (0.23 +/- 0.12 vs 0.31 +/- 0.20 microg/l, P = 0.043) and free testosterone (3.42 +/- 1.94 vs 4.59 +/- 2.97 ng/l, P = 0.009) and significantly lower levels of androstenedione (625.3 +/- 168.7 vs 697.0 +/- 211.9 ng/l, P = 0.017) when compared with controls. Multivariate linear regression analysis, adjusted for traditional cardiovascular risk factors, baseline and physiologic characteristics, showed a significant inverse relationship between both serum free testosterone (beta = -0.234, P = 0.028) and androstenedione (beta = -0.241, P = 0.028) levels with the presence of severe atherosclerosis of ICA. CONCLUSIONS: The study provides evidence of a positive association between low serum androgen levels and severe ICA atherosclerosis in postmenopausal women. It suggests that higher, but physiological, levels of androgens in postmenopausal women have a protective role in the development of atherosclerosis of ICA.

Carotid endarterectomy in the elderly: are the patient characteristics, the early outcome, and the predictors the same as those in younger patients?

BACKGROUND: The study was conducted to detect possible differences in patient characteristics, in early outcome, and in predictors for 30-day combined stroke and death rate between younger and older patients undergoing CEA. METHODS: Between March 1988 and November 2005, we recorded prospectively the data from every patient who underwent carotid artery surgery. Cardiovascular risk factors, comorbidities, anesthetic and surgical techniques, outcome, and survival were reviewed and compared between <75 age and >or=75 age group. RESULTS: We performed 1028 procedures in 742 patient. A total of 286 carotid endarterectomies were done in 213 patients 75 years or older. The number of cardiovascular risk factors per patient decreased with age. The risk factors tobacco use, hyperlipidemia, and the combination tobacco, hypertension, and hyperlipidemia were predominant in the younger group. Hypertension as only risk factor and the combination hypertension and hyperlipidemia were more present in the older group. The perioperative combined minor and major stroke and death rate was 2.8% in both groups. Attendant predictors for adverse outcome in the >or=75 age group were female sex and the combination of the risk factors diabetes, tobacco use, and hypertension. CONCLUSIONS: The type, the number, and the combinations of cardiovascular risk factors and the predictors for adverse outcome are different in the 2 age groups. Our observations indicate that people 75 years or older with small number of cardiovascular risk factors can undergo CEA with the same risk of perioperative stroke and death as the younger patients.

Chronic renal insufficiency and risk of early mortality in patients undergoing carotid endarterectomy.

We compared early outcome after carotid endarterectomy (CEA) in patients (n = 857 with 1,011 CEA interventions) with and without chronic renal insufficiency (CRI). Two groups were compared: a group with normal renal function (n = 909) and a group with CRI (creatinine >/=1.5 mg/dL and clearance of

Ropivacaine 3.75 mg/ml, 5 mg/ml, or 7.5 mg/ml for cervical plexus block during carotid endarterectomy.

OBJECTIVE: To examine the effect of 225 mg (7.5 mg/mL), 150 mg (5 mg/mL), and 112.5 mg (3.75 mg/mL) ropivacaine on quality of cervical plexus block during carotid endarterectomy. METHODS: Patients (n = 93) scheduled for carotid endarterectomy were randomized to receive a cervical plexus block with deep infiltration of 10 mL and superficial infiltration of 20-mL volumes of ropivacaine 7.5, 5.0, or 3.75 mg/mL. Pain, coughing, hemodynamic consequences of the block, postoperative visual analog scores, and pain satisfaction index were recorded. If necessary, anesthesia supplements with aliquots of 3 mL lidocaine 1% were given during surgery. RESULTS: Incidences of coughing and hoarseness were similar in all groups. More local anesthetic infiltrations were required in the ropivacaine 3.75-mg/mL and 5-mg/mL groups. Postoperatively, no intragroup differences were observed. A trend toward better pain satisfaction was observed in the ropivacaine 7.5-mg/mL group. CONCLUSION: The best quality of cervical plexus block associated with the smallest incidence of pain for patients undergoing carotid endarterectomy was obtained with 30 mL of 225 mg and 150 mg of ropivacaine, respectively.

Endovascular techniques in the management of acute arterioenteric fistulas.

PURPOSE: To report the use of endovascular techniques to emergently treat hemorrhagic complications of rare arterioenteric fistulas. CASE REPORTS: Two patients, a 71-year-old man and a 61-year-old woman, presented with acute bleeding arising from primary arterioenteric fistulas. In the first patient, a fistula between the iliac artery and the small intestine complicated laparoscopic treatment of acute appendicitis. In the second patient, irradiation of a metastatic cervical carcinoma led to a fistula between the right iliac artery and the terminal ileum. In both patients, the hemorrhage was controlled with implantation of a Jostent Peripheral Stent-Graft. The man is alive at 3 years with a patent endograft, but the woman died 1 month after treatment from complications of tumor progression. CONCLUSIONS: Endovascular application of covered stents provides an alternative treatment, avoiding extensive surgery. In cases of neoplastic erosion of a large vessel, endovascular stenting can offer a palliative solution.

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm.

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.