The mid-distal deep femoral artery: few important centimeters in vascular surgery

The deep femoral artery is an important artery in lower-limb revascularization. Employing its initial centimeters as either an inflow or an outflow site has been advocated by many authors. The purpose of this work was to highlight the importance of the mid-distal section of the deep femoral artery, underlining its indications and advantages. From January 1998 to December 2004, we performed, at the Misericordia Hospital Vascular Surgery Unit in Grosseto, Italy, 45 bypasses employing the mid-distal deep femoral artery as an inflow or outflow site. Twenty patients (44.4%) had nonhealing ulcers and/or gangrene, while the remainder (25 patients, 55.6%) presented with rest pain or severe claudication. In 41 cases (91.1%), the mid-distal deep femoral artery was used as the inflow site for peripheral bypasses. In four cases (8.9%), the mid-distal deep femoral artery was employed as the outflow site, twice (4.4%) after aortobifemoral branch thrombosis and twice (4.4%), in the same patient, after inguinal prosthetic infection healing. When the mid-distal deep femoral artery was employed as the inflow site, primary and secondary patency at 1 and 5 years were 92.72% vs. 95.20% and 57.39% vs. 72.81%, respectively. We had two early (<30 days) failures (4.4%) in patients with posterior tibial distal anastomosis, which required above-knee amputation. In two cases (4.4%), we had to perform a transmetatarsal amputation. In one patient, after healing of the inguinal prosthetic infection of an aortobifemoral bypass, we employed the mid-distal deep femoral artery both as inflow and as outflow site. This patient required a monolateral above-knee amputation after 5 months. The mid-distal deep femoral artery is a good outflow and inflow site in patients who have previously undergone surgical interventions in Scarpa's triangle, in those having inadequate vein segment, in those with local inguinal healed infection, and in obese patients. The surgical technique is a practical, easy, elegant, and fast procedure, along with being an optimal alternative to reexploration of scarred inguinal tissue.

Successful treatment and limb salvage of mucor necrotizing fasciitis after kidney transplantation with posaconazole

This is a case of mucormycosis complicated by necrotizing fasciitis in a renal transplant recipient on immunosuppressive therapy treated with posaconazole. Mucormycosis occurs most commonly as an opportunistic infection in the immunocompromised host. This patient, with predisposing risk factors for infection, including diabetes mellitus status post cadaveric renal transplantation on immunosuppressive therapy, is the first reported case of successful treatment of Mucor involving an extremity which was neither fatal nor required extremity amputation.

A Painless Method of Ultrasonically Assisted Debridement of Chronic Leg Ulcers: A Pilot Study

OBJECTIVES

Devitalized tissue in a recalcitrant leg ulcer is common and may impede healing. The aim of this study was to evaluate the use of a non-invasive low frequency ultrasound device to debride chronic leg ulcers as an adjunct to compression bandages therapy.

METHODS

19 patients with leg ulceration of at least 6 months were recruited. Low frequency ultrasound at 25kHz was delivered by a portable Sonaca--180 via a handheld probe, using normal saline as the irrigation/coupling medium. The ultrasound was applied for 10-20 seconds per probe head area onto the ulcer. Each leg underwent treatment at an interval of 2-3 weeks with compression bandages reapplied at the end of the treatment. Serial colour photographs were taken to evaluate the response at each visit.

RESULTS

Each patient received on average 5.7 treatments each ranged from 5-20 minutes depending on the ulcer size. Symptomatic relief (pain and odour reduction) was achieved in 6 patients. 7 patients achieved complete ulcer healing (mean ulcer size=4.72+/-SD 1.872cm(2)) but no response was observed in 8 patients. There were no major complications of the treatment which was relatively painless.

CONCLUSIONS

The application of low frequency ultrasound debridement may heal some recalcitrant ulcers when standard compression regimens have failed. It is cheap and does not require admission. The role of simple wound cleansing requires further investigation.

Comparison of inpatient bed rest and home convalescence following split thickness skin grafting to the lower leg

There has been a substantial move towards care of patients in an outpatient setting. This study was performed to determine if discharge home following split thickness skin grafting to the lower leg compromised graft results or morbidity compared with admission to hospital. Cases were reviewed retrospectively from the dermatology department's surgical records. All split thickness skin grafts to the lower legs over a 12-month period were included. All clinical notes were reviewed and phone calls made to patients and relatives. A total of 61 cases were included: 31 admitted as inpatients, 30 discharged home. There was no significant difference between the two groups' age, sex or comorbidities. A trend was seen in inpatients towards increased infection (P = 0.19) and venous thrombosis (P = 0.34). There is a lack of significant difference between admitted and discharged patients in all outcomes including bleeding, number of dressing clinic follow ups and graft loss. These results suggest that home convalescence after split thickness skin grafting to the lower legs compares favourably with inpatient care.

[Evaluation and surgical treatment for chronic wound of leg and foot]

OBJECTIVE

To investigate the optimal operation method for the management of various chronic wounds in legs and feet.

METHODS

Fifty-one chronic wounds were evaluated according to infection, inflammatory response, and distribution in different areas of the leg and foot. Preoperative treatment was given accordingly, then transposition of skin flap, skin grafting, or amputation was performed. The healing rate after single session operation and average hospitalization were statistically analyzed.

RESULTS

The wound healing rate after single session operation was 86. 3% , the average hospital stay was (17. 8 +/- 2. 1) days, and the appearance and function of the leg and foot after operation was satisfactory.

CONCLUSION

The appropriate preoperative treatment and operation method conforming to the wound location and evaluation are of vital importance in the management of chronic wounds in the leg and foot. Operation is one of the most effective ways to repair chronic wounds in the leg and foot, and it can shorten the wound healing process and restore the function.

[Lower limb venous angiodysplasia as a cause of chronic venous insufficiency: specific diagnosis and treatment]

The paper presents a current understanding of chronic venous insufficiency that develops in venous forms of dysplasia. Management of venous dysplasia must be based on multidisciplinary approach including comprehensive diagnosis (predominantly noninvasive), integrative surgical and non-surgical treatment. Modern therapy must be complex and carried out in highly specialized facilities. Best functional and esthetic results can be achieved only through combined therapy. When surgical or non-surgical interventions are inappropriate or impossible, management focus must be placed on clinical control of vascular anomaly (follow-up and compression-based conservative treatment) aimed at minimization of its unfavorable impact on vital functions and at quality of life improvement.

Long-term results of venous blood flow arterialization of the leg and foot in patients with critical lower limb ischemia

This paper analyzes the long-term results of venous blood flow arterializations of the leg and foot, performed in 67 patients with critical lower limb ischemia at the Department of Vascular Surgery, Russian Scientific Center of Surgery, over the period from 1996. Indications for surgery were occlusions of the arteries of the femoropopliteotibial segment, which excluded the possibility of performing reconstructive bypass graftings. Analysis of the long-term results of venous blood flow arterialization of the leg and foot evidences its high efficacy. The use of such operation in patients with initial critical lower limb ischemia enables amputation of the involved limb to be avoided in 64% of cases and ensures the high level of physical and social adaptation of the patient for the nearest 2-3 years.

Excision and meshed skin grafting for leg ulcers resistant to compression therapy

Background

The aim of this study was to determine the success of excision and meshed skin grafting for chronic leg ulcers. The effects of different ulcer aetiology and ulcer size on outcome were also assessed.

Methods

All patients who had excision and mesh grafting for chronic leg ulceration between January 1996 and December 2004 at St Thomas' Hospital were reviewed. Recurrence was classified as any breakdown of the ulcer during follow-up.

Results

Sixty-two patients with 100 chronic leg ulcers underwent operation. Seventy-two of the ulcers were venous and the median ulcer size was 36 (range 1·5–192) cm2. Only three patients left the hospital with their ulcers unhealed, but ulcers had recurred in 28 (28 per cent) by 2 months. A further 17 ulcers recurred later, with just over half (55 per cent) remaining healed by 5 years. There was no difference between the recurrence rates of venous ulcers and ulcers of other aetiologies (P = 0·980), or large (more than 10 cm2) and small ulcers (P = 0·686).

Conclusion

Wide local excision and meshed skin grafting benefitted over half of these patients with refractory leg ulcers. Recurrence was most likely to occur in the first 2 months and, provided that ulcers were healed at this time, there was a low rate of further breakdown.

Autologous full-thickness skin substitute for healing chronic wounds

BACKGROUND

Chronic wounds represent a major problem to our society. Therefore, advanced wound-healing strategies for the treatment of these wounds are expanding into the field of tissue engineering.

OBJECTIVES

To develop a novel tissue-engineered, autologous, full-thickness skin substitute of entirely human origin and to determine its ability to heal chronic wounds.

METHODS

Skin substitutes (fully differentiated epidermis on fibroblast-populated human dermis) were constructed from 3-mm punch biopsies isolated from patients to be treated. Acellular allodermis was used as a dermal matrix. After a prior 5-day vacuum-assisted closure therapy to prepare the wound bed, skin substitutes were applied in a simple one-step surgical procedure to 19 long-standing recalcitrant leg ulcers (14 patients; ulcer duration 0.5-50 years).

RESULTS

The success rate in culturing biopsies was 97%. The skin substitute visibly resembled an autograft. Eleven of the 19 ulcers (size 1-10 cm2) healed within 8 weeks after a single application of the skin substitute. The other eight larger (60-150 cm2) and/or complicated ulcers healed completely (n = 5) or continued to decrease substantially in size (n = 3) after the 8-week follow-up period. Wound healing occurred by direct take of the skin substitute (n = 12) and/or stimulation of granulation tissue/epithelialization (n = 7). Skin substitutes were very well tolerated and pain relief was immediate after application.

CONCLUSIONS

Application of this novel skin substitute provides a promising new therapy for healing chronic wounds resistant to conventional therapies.

Skin grafting of a chronic leg ulcer with combined Versajet?-V.A.C. therapy

A new method for surgical wound debridement is the Versajet hydrosurgery technique. This technique uses a high velocity jet of sterile saline with a speed up to 1,078 km/h (670 miles/h). By using the Venturi effect (fluid speeds up in a restriction, reducing its pressure and producing a partial vacuum), a simultaneous vacuum is created across the operating window of the handpiece. The application of this high velocity fluid jet to a chronic wound enables precise debridement without collateral tissue damage. The vacuum-assisted closure (V.A.C.) therapy is used for chronic wounds to induce faster wound healing. This system creates a vacuum-induced negative pressure to a specific wound area resulting in an accelerated formation of granulation tissue in the wound bed. We present a patient who experienced rapid wound healing when both of these techniques were combined to clean the wound. After split-thickness skin grafting, V.A.C. therapy was continued. The result was excellent graft acceptance with complete wound healing. This case is unique in that a combination of both therapies resulted in complete wound healing.

Infrainguinal revascularization based on duplex ultrasound arterial mapping

AIM

Recent reports have advocated duplex ultrasound arterial mapping (DUAM) as the sole preoperative imaging modality for planning infrainguinal revascularization. This study reports the outcome of arterial revascularization procedures for chronic limb ischemia based on DUAM.

METHODS

From January 2002 to December 2004, 253 patients (175 men, 78 women) underwent infrainguinal revascularization based on DUAM. The indications for surgery were severe claudication (11%), rest pain (15%), gangrene (40%), non-healing ulcer (34%). Preoperative evaluation consisted of DUAM alone in 208 cases (82%) or a combination of DUAM and contrast arteriography (CA) in 30 (12%) and intraoperative angiography or direct exploration in 15 (6%). DUAM allowed imaging from the distal aorta to the pedal arteries and the selection of inflow and outflow bypass anastomosis sites. CA was deemed necessary due to technical difficulties or medico-legal reasons.

RESULTS

DUAM procedure time averaged 90+30 min. Proximal anastomosis was located in common femoral arteries in 202 cases, popliteal in 51. Distal anastomosis was to the tibial arteries in 144 cases and pedal arteries in 109. Primary patency was 89% and 67% at 12 and 36 months. Secondary patency was 93% and 82% at 12 and 36 months.

CONCLUSIONS

This experience shows that DUAM may be a safe alternative to CA for patients with chronic limb ischemia. Adequate training and experience is necessary to utilize this technique as the sole preoperative imaging modality for planning infrainguinal revascularization.

Early Marjolin's ulcer in Bureau-Barriere syndrome

Bureau-Barrière syndrome (BBS) describes a rare destructive process affecting skin and bone resulting from an acquired unilateral or bilateral polyneuropathy. Clinically, it is characterized by a triad of symptoms, namely, acral ulcerations, polyneuropathy, and bone lesions. To date, the development of Marjolin's ulcer in the course of BBS has not been described to the authors' knowledge.

Autoperipheral blood mononuclear cell transplantation improved giant ulcers due to chronic arteriosclerosis obliterans

We report the case of a 74-year-old man with Fontaine stage IV chronic arteriosclerosis obliterans who had been suffering from inveterate giant skin ulcers on the dorsum and heel of the right foot. As conventional medical treatments had not improved these ulcers and surgical treatment was considered unfeasible, amputation of the right lower limb below the knee appeared to represent the only option. The patient was admitted to Tottori University Hospital to attempt a new angiogenic therapy using auto-mononuclear cell transplantation to avoid amputation. On admission, neither right ankle blood pressure nor transcutaneous partial pressure of oxygen at the right toe were detectable. The patient had a history of multiple cerebral infarctions, and collection of mononuclear cells from bone marrow was considered too difficult, so collection of peripheral blood mononuclear cells was selected. Transcutaneous partial pressure of oxygen and skin temperature in the treated limb started to improve from 2 weeks after implantation. Ulcer size was recognizably reduced by 1 month after treatment. Partial auto-skin implantation on the right heel was performed 2 months after treatment, and the giant skin ulcer was finally completely covered. No adverse effects were noted during follow-up lasting 1 year. These results suggest that peripheral blood mononuclear cell implantation may offer a suitable alternative rescue therapy for patients with critical limb ischemia whose general condition is not good.

Gamma-irradiated human skin allograft: a potential treatment modality for lower extremity ulcers

Gamma-irradiated human skin allograft consists of epidermis and dermis. Unlike bioengineered tissues which require cold storage and timely use once received from the manufacturer, gamma-irradiated human skin allograft can be stored for as long as 24 months at room temperature. This modality is applied in a fashion similar to that of bioengineered skin grafts. In this article, we present case studies with concise reviews of the available evidence to discuss the potential use of gamma-irradiated human skin allograft on wounds in the lower extremity.

Experience with local negative pressure (vacuum method) in the treatment of complex wounds

CONTEXT AND OBJECTIVE

Use of topical negative pressure over difficult-to-heal wounds has been studied. The objective of this study was to analyze the effects from negative pressure in the treatment of complex wounds.

DESIGN AND SETTING

Case series developed at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo.

METHODS

Twenty-nine patients with complex wounds were treated with the vacuum system and then underwent a surgical procedure to close the wound.

RESULTS

85% of the skin grafts took well, and 87.5% of the local flaps were successful, thus demonstrating adequate wound preparation. The wounds were closed within shorter times than observed using other conventional treatments In two cases, the vacuum system was also used to stabilize the skin grafts over the wounds.

CONCLUSIONS

Use of the vacuum method is safe and efficient for preparing wounds for surgical closure. It allows for an improvement of local wound conditions, and healthy granulation tissue develops with control over local infection.

Prevalence of lower-extremity amputation among patients with diabetes mellitus: is height a factor?

BACKGROUND

Taller diabetic patients are at higher risk of peripheral sensory loss than shorter diabetic patients and thus may be at increased risk of lower-extremity ulcers and amputation. In a large telephone survey, the prevalence of lower-extremity amputation among patients with diabetes mellitus was determined and the association between height and lower-extremity amputation evaluated.

METHODS

Of 256,036 patients identified from hospital and clinic databases who had a diagnosis of diabetes and were seen at those institutions between 1995 and 1998, 128,572 were randomly selected to be interviewed by telephone between 1995 and 2002. Of the 93,484 patients who agreed to be interviewed, 386 were excluded (age < 18 years); this left 93,116 diabetec patients (42,970 men and 50,146 women) for inclusion in the study.

RESULTS

Of the 93,116 patients interviewed, 3259 (3.5%) had type 1 diabetes. Lower-extremity amputation was performed in 1.7% and 0.8% of the patients with type 1 and type 2 diabetes, respectively. The prevalence of amputation did not differ significantly between men and women with type 1 diabetes but was significantly higher among men than among women with type 2 diabetes (0.9% v. 0.7%). Height (every 10-cm increment) was significantly associated with lower-extremity amputation (adjusted odds ratio [OR] 1.16, 95% confidence interval [CI] 1.03-1.32). In a subgroup of 9295 patients for whom data on fasting plasma glucose levels and dyslipidemia were available, and after additional adjustment for these 2 variables, body height remained an independent predictor of lower-extremity amputation (adjusted OR for every 10 cm of height 1.79, 95% CI 1.14-2.82).

INTERPRETATION

Height is an independent predictor of lower-extremity amputation among patients with type 1 and type 2 diabetes mellitus.

[Radiation arteritis- and radiodermitis-induced leg ulcer: surgical revascularization]

A forty-four-year old man was hospitalized for diagnosis and treatment of a left leg ulcer which did not heal despite good compliance with a three-month medical regimen. Twenty years before he had undergone surgical curettage and radiotherapy (81 gy) for an osteosarcoma of the upper third of the left tibia. He was considered completely cured with regular findings. On examination he had a 5 X 7 cm deep ulcer with raised margins and no signs of infection, localized on the radiodermatitis on the medial aspect of his left leg. Arterial examination confirmed the left arteriopathy with absence of distal pulses; the Ankle Brachial Pressure Index was 0.69 and the foot TcPO2 27 mmHg. Arteriography confirmed the localized left lesions with three distal popliteal and proximal arterial occlusions, all other arteries being strictly normal. Arterial and dermatological radiation leg ulcer was retained as the etiological diagnosis. As the ulcer was very painful, extensive and limited walking distance, surgical revascularisation was undertaken because endoluminal revascularization was impossible. A femoroperoneal saphenous bypass was performed with surgical incisions beyond the radiodermatitis area. Two months after a split skin graft, the ulcer was considered healed and the patency of the by-pass confirmed on duplex examination. This is the first case report of a successful distal by-pass performed for radiation arteritis and ulcer healing. Long-term follow up should be reported.

A retrospective review of 20 hypertensive leg ulcers treated with mesh skin grafts

BACKGROUND

Few articles have been published about hypertensive leg ulcers and their surgical treatment. Since mid of the year 2000, it has been our policy to treat all hypertensive leg ulcers very early with mesh split-thickness skin grafts. The present series consists of 15 patients whose hypertensive leg ulcers, including five bilateral cases, were treated with 20 mesh grafts from 2000 to 2002.

SUBJECTS AND METHODS

All patients, nine women and six men, had a long history of hypertension. The same surgical procedure was applied to all 15 patients: a complete mechanical debridement of all necrotic tissues, immediately followed by mesh skin grafting.

RESULTS

Patients were discharged from the hospital after an average post-operative period of 16 days. Upon leaving the hospital, the patients had lesions completely healed in 14 of 20 cases. The graft take had been complete after an average period of 14 days. In six cases, one or two very small patches of skin graft had necrosed and complete healing required an additional period of 1 to 3 months. In all 20 cases, pain had disappeared within 1 week from surgery.

DISCUSSION

All patients were on opioid therapy before surgery. With medical treatment only, hypertensive leg ulcers used to heal after a mean period of 15 months. After surgery, the average healing period was 2 weeks and opioids were stopped within 1 month after surgery.

CONCLUSION

The review of the present series shows that early mesh grafting of hypertensive leg ulcers is beneficial, because healing is very quick and the pain will disappear quasi-instantly.