Current controversies in shock and resuscitation

Many controversies and uncertainties surround resuscitation of hemorrhagic shock caused by vascular trauma. Whereas the basic pathophysiology is better understood, much remains to be learned about the many immunologic cascades that lead to problems beyond those of initial fluid resuscitation or operative hemostasis. Fluid therapy is on the verge of significant advances with substitute oxygen carriers, yet surgeons are still beset with questions of how much and what type of initial fluid to provide. Finally, the parameters chosen to guide therapy and the methods used to monitor patients present other interesting issues.

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms

PURPOSE

Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally.

METHODS

A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm.

RESULTS

Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months).

CONCLUSIONS

IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.

Lower-extremity wounds. 1: Vascular disease assessment

Non-healing arterial and/or diabetic wounds of the lower extremity are the reflection of a systemic process — that is, the presence of atherosclerosis and/or diabetes mellitus. The disease process is accelerated by specific risk factors including smoking, obesity, hypertension, decreased activity, lipid disorders and infection.

Lower-extremity wounds. 2. Management options

Various disorders and risk factors prevent wound healing in patients with peripheral vascular disease. These mostly can be treated with non-pharmacological interventions, such as smoking cessation and diabetes management.

Acute management of exposure to liquid ammonia

Ammonia injury is an uncommon injury, but it is associated with high morbidity and mortality. This case report demonstrates the pathophysiology and treatment of both cutaneous burn wounds and inhalation injury caused by ammonia. Frequent bronchoscopy was used to attempt to avoid intubation and its associated morbidity. The patient remained extubated, but later he required skin grafts to close his wounds after healing of his pulmonary injury. A review of the management of inhalation injury is also discussed. Ammonia injury can cause a severe inhalation injury. Bronchoscopy can be a useful tool to avoid intubation.

Peripheral vascular disease intervention in patients with end-stage renal disease: few complications in those treated with peritoneal dialysis

BACKGROUND

We assessed the results of peripheral vascular surgery in patients with end-stage renal disease (ESRD) who were being treated with peritoneal dialysis.

METHODS

Sixty-seven ESRD patients on peritoneal dialysis who had peripheral vascular surgery were assessed retrospectively for preoperative risk factors, primary and secondary patency rates, and mortalitv. The study group had 48 proximal femoral-popliteal bypasses, 12 distal femoral-popliteal bypasses, and 7 distal femoral-tibial and/or peroneal revascularizations.

RESULTS

Among 67 peritoneal dialysis patients, 15 deaths (22%) occurred over 68 months (mean, 14 months).

CONCLUSION

Patients on peritoneal dialysis had adequate patency rates and length of survival after peripheral vascular surgery when maintained on peritoneal dialysis.

Management of failed or failing infrainguinal bypasses with distal correctable lesions

The goal of this study was to assess the management of failed or failing infrainguinal bypasses with distal correctable lesions. A retrospective analysis of 94 procedures was performed for 72 (77%) failed and 22 (23%) failing infrainguinal bypasses with distal correctable lesions in 94 patients. The 94 procedures included 50 (53%) balloon angioplasties and 44 (47%) distal vein graft extensions from the previous graft to the distal artery. Preprocedural thrombolytic therapy was performed in 62 of 94 limbs with a failed graft, and complete thrombolysis was achieved in 30 of 94. The results of thrombolytic therapy (complete or incomplete thrombolysis) or the means of revision procedure (balloon angioplasty or distal vein graft extension) did not affect the patency. Lower patency was observed for women, patients with a secondary bypass, and grafts with multiple episodes of revision. We conclude that the patency of failing infrainguinal bypasses after revision of distal lesions was affected not by means of therapy but by previous vascular procedures, the usual risk factors, and female gender.

Lemierre's syndrome

We describe a 32-year-old woman who had temperatures increasing over 7 days from 100.7 degrees F to 104.0 degrees F. She had an upper respiratory infection and swelling of the left side of the neck. She was diagnosed with Lemierre's syndrome.

Pneumothorax after nasoenteral feeding tube placement

Nasoenteral tubes are placed routinely for feeding in patients in intensive care units and medical-surgical floor settings. Safe placement in the stomach/postpyloric location is performed by a wide array of medical personnel. We report a patient with placement of a nasoenteral tube into the pleural cavity.

Modification of a choledochoscope for extraction of difficult biliary stones

Cholelithiasis is a common problem in the United States, affecting 10 to 15 per cent of the population. Although only one per cent of these patients have intrahepatic gallstones their discovery intraoperatively may present a technical challenge for the surgeon. This paper describes a simple method for dislodging difficult intrahepatic biliary stones: modification of a rigid choledochoscope to permit use of a biliary Fogarty catheter and Segura basket under direct visualization.

Current assessment of thromboembolic disease and pregnancy

This study was undertaken to assess incidence of deep venous thrombosis and pulmonary emboli in an inner-city pregnant population. Thromboembolic disease is believed to occur in 0.05 to 0.1 per cent of all pregnancies. Historically, postpartum thromboembolic disease was more common; decreased hospital stay may shift the thromboembolic disease to the antepartum period. A 5-year retrospective review of 4910 births assessed for incidence of thromboembolic disease, methods of diagnosis and treatment, and risk factors. A total of 4910 deliveries with 3978 transvaginal resulted in 30 episodes of deep venous thrombosis and five pulmonary emboli. All incidences of deep venous thrombosis but one were left-sided; four of five pulmonary emboli were postpartum. Of the epidsodes of deep venous thrombosis 17 per cent were first trimester, 50 per cent second trimester, 27 per cent third trimester, and 6 per cent postpartum. The diagnosis was confirmed by duplex scan in 24 of 30 patients. Heparin was the standard treatment. Deep venous thrombosis in pregnancy is most common in the second trimester; pulmonary emboli remain most common postpartum.

Visceral artery aneurysms: experience in a tertiary-care center

Visceral artery aneurysms (VAAs) often rupture and cause serious morbidity or death. The purpose of this study was to identify conditions associated with VAA in a series of 30 patients treated at our institution from 1988 through 1998. Demographics, types of aneurysms, associated conditions, diagnoses, treatments, and outcomes were recorded and analyzed. Thirty patients (16 men and 14 women) with VAA were identified. The arteries involved were splenic (eight), renal (ten), hepatic (nine), hypogastric (one), celiac (one), and pancreaticoduodenal (one). Five of eight (63%) splenic artery aneurysms occurred in women; however, gender was not a factor in other aneurysmal groups. Splenic artery aneurysm also was associated with cirrhosis in four of the eight (50%) patients. Five of the nine (56%) hepatic artery aneurysms were associated with cirrhosis; two of these were pseudoaneurysms that occurred after liver transplantation. Five of ten (50%) renal artery aneurysms were associated with juxtarenal abdominal aortic aneurysms. Celiac and pancreaticoduodenal aneurysms were associated with gastrointestinal bleeding. Treatments included surgery (19), embolization (eight), and observation alone (three). These data demonstrate that association with other conditions varies according to subgroups of VAA. Despite advances in diagnosis and therapy the heterogeneity of VAA suggests that management must remain individualized.

Buerger's disease affecting mesenteric arteries: a rare cause of intestinal ischemia--a case report

Buerger's disease is a recurrent, inflammatory, segmental, vasoocclusive disease. Typically, the disease affects middle-aged male smokers and involves arteries and veins of extremities. Buerger's disease involving visceral vessels is rare. The authors report on a 51-year-old man with peripheral arterial disease and recurrent intestinal ischemia secondary to Buerger's disease. Clinical and histopathologic features of this case illustrate the life-threatening nature of visceral involvement in Buerger's disease.

Peripheral arterial disease. Medical management in primary care practice

Peripheral arterial disease (PAD) is caused by atherosclerosis, the leading cause of death and disability in patients age 50 and older. PAD progresses gradually and silently over many years, occluding the lumen of arteries that supply blood to the extremities. Symptoms of peripheral arterial insufficiency include intermittent claudication, rest pain, and impotence. Nonoperative management--including the control of risk factors such as hypertension, diabetes, hyperlipidemia, and smoking--is the most effective method to lower the risk of morbidity from PAD. Diagnostic technologies such as color duplex imaging, MRI, and MRA complement the clinical assessment of PAD and provide a stronger foundation for treatment decisions in the primary care setting.

Use of telehealth for chronic wound care: a case study

Use of telehealth in wound care continues to expand as technology is enhanced and clinicians become more familiar with use of the new technology as a supplement to usual care. This article describes the Telehealth Wound Care Program implemented at Mount Sinai Hospital Home Health Agency and Mount Sinai Hospital Wound Care Center. Results of the wound care provided for one patient are included in the case study described in this article. The authors note the many benefits of telehealth as an adjunct to usual therapy in wound care.

Nontropical pyomyositis: analysis of eight patients in an urban center

Nontropical pyomyositis is rare and usually associated with immunodeficiency virus (HIV) infection. This study assessed manifestations and response to treatment of nontropical pyomyositis in an area with a high prevalence of HIV seropositivity. We undertook a chart review of eight consecutive patients treated for pyomyositis - primary infection of skeletal muscles - from 1988 through 1998. All patients complained of myalgia; four (50%) had fever and six (75%) had leukocytosis. Muscles involved were deltoid, quadriceps, gluteus, and psoas. Six (75%) patients had identifiable risk factors for pyomyositis: HIV seropositivity (two), history of intravenous drug abuse (one), chronic paraplegia and malnutrition (one), diabetes and chronic renal failure (one), and leukemia (one). One patient had had streptococcal pharyngitis previously but was otherwise healthy; another, a 2-year-old, had no evidence of underlying disease. Staphylococcus aureus was the most common organism isolated (50%). Four patients were treated with incision and drainage plus antibiotics; the remaining four patients were treated with intravenous antibiotics only; all recovered. Nontropical pyomyositis, which is often associated with HIV seropositivity or chronic illness, has a favorable outcome. Treatment can be effective even without surgical intervention.

Secondary distal extension of infrainguinal bypass: long-term limb and patient survival

The potential benefits of secondary distal extension vein grafts required after failing or failed initial infrainguinal bypasses were evaluated. Outcomes of secondary distal extension bypass procedures (n = 58) performed between July 1983 and March 1993 were reviewed. Patients (n = 51) had critical ischemia or tissue loss, with an average of 2.8 previous vascular procedures. The 58 initial infrainguinal bypasses included 38 above-the-knee and 13 below-the-knee femoropopliteal, 5 femorodistal, and 2 popliteal-distal. Thirty-nine of the 58 femoropopliteal grafts were prosthetic. The extension bypasses included popliteal-tibial, graft-tibial, and peroneal-plantar. They were performed for recurrent or persistent ischemia after failed initial infrainguinal bypasses in limbs, and with still-patent bypasses. All extension bypasses were vein conduits. Mean follow-up was 59 (range: 6 to 164) months. The cumulative life-table 5-year survival rate for all patients was 95%. The 27-month limb-salvage rate was 70%. Our findings indicate that patients with advanced peripheral vascular disease may have prolonged survival, and extension bypasses contribute significantly to their limb salvage. Thus, aggressive application of extension bypass to save threatened limbs is supported.

Outcomes of venous ulcer care: results of a longitudinal study

A longitudinal study involving 81 patients with venous ulcers was conducted to explore the outcomes and cost of wound care in a home healthcare (HHC) setting and an outpatient care setting. Ulcers were managed with a saline gauze or hydrocolloid dressing and compression hosiery, or covered with an Unna's boot. Outcomes did not vary between physician's office and home care. Patients preferred home care, but costs and charges were much higher for HHC than for patients managed in the physician's office. Recurrence rates and costs varied greatly. Eighty-eight percent of ulcers in the saline dressing group did not heal or recurred compared to 21% of ulcers in the Unna's boot and 13% of ulcers in the hydrocolloid dressing group. The data also suggest hydrocolloid dressings are more cost-effective than Unna's boot or saline-gauze dressings. Controlled clinical studies to ascertain the cost-effectiveness of venous ulcer care in different patient care settings and the use of different treatment modalities, as well as care system oriented toward outcome for the patient rather than service, design, and distribution, are needed.

Gender does not impact infrainguinal vein bypass graft outcome

BACKGROUND

The percentage of women requiring infrainguinal bypass graft operations continues to increase, whereas the effect of gender on postoperative outcome remains unclear. The purpose of this study was to assess the influence of gender on patient selection and outcome in patients requiring infrainguinal vein bypass grafting procedures.

METHODS

This retrospective study reviewed 217 infrainguinal vein bypass grafts performed over an 8-year period. Medical records and patient interviews were used to determine study measures and outcomes. Gender and multiple covariables affecting patient survival were analyzed; postoperative complications and graft patencies were examined. Bivariate and life-table analyses were conducted, followed by multivariate analysis with the Cox proportional hazards model.

RESULTS

No statistical differences existed between men and women for age, diabetes, cardiac disease, tobacco use, hypertension, stroke, renal disease, or prior contralateral bypass or major amputation. Women were more likely to be black (P =.014) and have a spliced vein graft (P =.035). No differences were noted between the 2 groups for 30-day morbidity rates-except women had more incisional complications (P =.01)-or for survival (P =.45), primary-patency (P =.57), secondary-patency (P =. 79), or limb-salvage rates (P =.40). Multivariate analysis showed that gender had no role in affecting survival rates.

CONCLUSIONS

Gender does not affect graft patency, limb salvage, or survival rates. There should be no introduction of a gender bias into management of infrainguinal occlusive disease.

Complications of lower extremity arteriovenous grafts in patients with end-stage renal disease

BACKGROUND

More data are needed to assess lower extremity angioaccess sites for hemodialysis.

METHODS

We did a retrospective review of 843 consecutive hospital records of upper and lower extremity arteriovenous (AV) fistulas from 1992 to 1996.

RESULTS

Lower extremity grafts accounted for 16% (134/843) of patients in this series. Complications occurred in 58 of 134 patients (43%) and were more prevalent in women, blacks, diabetic, and hypertensive patients, but not of statistical significance. Dialysis was done for a mean duration of 13.3 years, with a mean graft patency rate of 13.8 months. The 12-month survival rate of lower extremity AV grafts was 62% (83/134). Complications in the lower extremity AV graft group (58 patients) included infections in 27 patients (46%), thrombosis within 30 days in 16 (28%), pseudoaneurysm in 9 (16%), and graft hemorrhage in 6 (10%).

CONCLUSIONS

There is a decreased patency rate in lower extremity AV grafts.

Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing

HYPOTHESIS

In patients with diabetic foot and pressure ulcers, early intervention with biological therapy will either halt progression or result in rapid healing of these chronic wounds.

DESIGN

In a prospective nonrandomized case series, 23 consecutive patients were treated with human skin equivalent (HSE) after excisional debridement of their wounds.

SETTING

A single university teaching hospital and tertiary care center.

PATIENTS AND METHODS

Twenty-three consecutive patients with a total of 41 wounds (1.0-7.5 cm in diameter) were treated with placement of HSE after sharp excisional debridement. All patients with pressure ulcers received alternating air therapy with zero-pressure alternating air mattresses.

MAIN OUTCOME MEASURE

Time to 100% healing, as defined by full epithelialization of the wound and by no drainage from the site.

RESULTS

Seven of 10 patients with diabetic foot ulcers had complete healing of all wounds. In these patients 17 of 20 wounds healed in an average of 42 days. Seven of 13 patients with pressure ulcers had complete healing of all wounds. In patients with pressure ulcers, 13 of 21 wounds healed in an average of 29 days. All wounds that did not heal in this series occurred in patients who had an additional stage IV ulcer or a wound with exposed bone. Twenty-nine of 30 wounds that healed did so after a single application of the HSE.

CONCLUSIONS

In diabetic ulcers and pressure ulcers of various durations, the application of HSE with the surgical principles used in a traditional skin graft is successful in producing healing. The high success rate with complete closure in these various types of wounds suggests that HSE may function as a reservoir of growth factors that also stimulate wound contraction and epithelialization. If a wound has not fully healed after 6 weeks, a second application of HSE should be used. If the wound is not healing, an occult infection is the likely cause. All nonischemic diabetic foot and pressure ulcers that are identified and treated early with aggressive therapy (including antibiotics, off-loading of pressure, and biological therapy) will not progress.

Splenic artery aneurysm in the 1990s

Splenic artery aneurysms (SAA), although rare, are the most common visceral artery aneurysms and are known for their potential for rupture. Pregnancy and portal hypertension have been known as major risk factors. With improved methods of diagnosis and minimally invasive therapy, management and outcome of SAA may change significantly. The purpose of this study was to analyze our institutional experience with SAA during the past decade. Charts of all patients (six women, three men; mean age, 60.5 [range: 31 to 81] years) with diagnoses of SAA from 1988 to 1999 were reviewed. Associated conditions included essential hypertension (6), portal hypertension (3), diabetes (1), intracranial aneurysm (1), and polyarteritis nodosa (1). Six patients were asymptomatic, and three had ruptured SAA. Diagnosis was made by angiography (2), computed tomography (3), ultrasonography (3), and exploratory laparotomy (1). Six patients underwent surgery (five required splenectomy), one had embolization, and two had no intervention. Three postoperative deaths occurred-two (intracranial aneurysm, myocardial infarction) in the first month, one (sepsis) in the ninth month. An association of liver disease with SAA was confirmed; however, no association with pregnancy was noted. Surgical treatment followed traditional methods, and mortality correlated with presence of severe comorbidity.

Tibial shaft fractures with an associated infrapopliteal arterial injury: a survey of vascular surgeons opinions on the need for vascular repair

OBJECTIVE

To determine current practice for tibial arterial revascularization in trauma patients with tibial shaft fractures associated with infrapopliteal arterial injuries.

DESIGN

Nationwide survey of board-certified vascular surgeons, proportionally stratified by geographic region.

METHODS

We surveyed a random sample (probability sample stratified by geographic region) of 200 members of the 729 active members of the Society for Clinical Vascular Surgery. We designed a twenty-one-item questionnaire to elicit opinions on the need for vascular repair for a variety of clinical scenarios.

RESULTS

Completed questionnaires were returned by fifty-one vascular surgeons. For the eight isolated and combined infra-popliteal arterial injuries we studied, agreement between vascular surgeons as to the need for arterial repair was better for scenarios with clinical evidence of limb ischemia than for those without clinical evidence of limb ischemia. For injuries with clinical evidence of limb ischemia, excellent agreement (90 percent or more of respondents agreeing) was seen for five of the eight injuries, good agreement (80 to 89 percent of respondents agreeing) was seen for two injuries, and poor agreement (less than 70 percent of respondents agreeing) was seen for one injury. For injuries without clinical evidence of limb ischemia, excellent agreement was seen for one injury, good agreement was seen for two injuries, fair agreement (70 to 79 percent of respondents agreeing) was seen for three injuries, and poor agreement was seen for two injuries.

CONCLUSIONS

A review of the literature and results of our study suggest that no standardized protocol exists in the current practice of revascularization of infrapopliteal arterial injuries with concomitant tibial shaft fractures; disagreement among vascular surgeons was particularly common for cases where a vessel was known to be injured but there was no clinical evidence of limb ischemia. Our study highlights the need for randomized prospective studies so that standardized protocols can be developed for these serious injuries. Because of the relatively small numbers of this type of injury and the wide variety of injury patterns seen, a study such as this would best be designed as a multi-center study.

Nonocclusive mesenteric infarction in hemodialysis patients

BACKGROUND

Dialysis patients develop nonocclusive mesenteric ischemia (NOMI) at an increased rate. Previous studies have associated atherosclerosis and hemodialysis-induced hypotension as inciting factors for NOMI development. A retrospective review of 29 of 1,370 longterm hemodialysis patients who developed NOMI from January 1992 to December 1997 was performed. The NOMI patients were compared with a similar profile of hemodialysis patients to identify risk factors for the development of NOMI and for outcomes assessment.

STUDY DESIGN

All NOMI patients had hypotensive episodes during hemodialysis the week before the development of abdominal symptoms, and additional risk factors of hypertension (83%), diabetes (55%), and atherosclerosis (38%). The majority of patients (83%) experienced abdominal pain more than 24 hours before admission. Sixty-six percent of patients had leukocytosis on admission laboratory data.

RESULTS

Sixteen patients (55%) had ischemia of the small bowel, all underwent laparotomy, and nine (56%) died. Thirteen patients (45%) had ischemia of the colon and were managed nonoperatively; four (31%) of them died. Overall mortality rate for NOMI was 45%.

CONCLUSIONS

NOMI occurs at an increased rate in hemodialysis patients. Identification of patients at high risk for NOMI and dose monitoring of filtration rates may impact on the high mortality of this disease.

Use of venous duplex scans to evaluate symptoms of deep vein thrombosis: an analysis of ultrasound usage by various medical specialties

In today's environment of cost-containment and utilization management, duplex ultrasound is often overused to evaluate symptoms of deep venous thrombosis/thrombophlebitis (DVT), reflecting the low diagnostic yield of such studies. We investigated the use of venous duplex scans by various medical specialties to determine whether a tendency exists to overuse this diagnostic tool by one specialty compared with others and to assess the cost-effectiveness of ordering this test for acute venous disease changes. We retrospectively reviewed the results of venous duplex ultrasound studies for 330 consecutive patients with suspected DVT for a 1-year period. Our analysis showed that 51 of 330 (16%) of all duplex scans ordered in our institution were positive for DVT. Internists, as a group, ordered 185 studies of which 26 were positive (14%). The surgeons' requests for duplex studies resulted in 23 of 137 (17%) confirmed positive studies. The overall positive examination rate was 16 per cent, which is not only suboptimal as a diagnostic tool, but also cumbersome with regard to health care cost-containment.

Deep venous thrombosis and pulmonary embolism in bilateral lower-extremity amputee patients

OBJECTIVE

To determine the incidence of deep venous thrombosis and pulmonary emboli and the value of an inferior vena cava filter in patients with bilateral lower-extremity amputations, and to determine the incidence of pulmonary emboli after filter placement.

DESIGN

Retrospective study with a follow-up of 3 to 64 months.

SETTING

Inner-city university hospital.

PATIENTS

Twenty-seven consecutive patients with bilateral lower-limb amputation.

RESULTS

Age, sex, and race were assessed, and had no impact on the incidence of pulmonary embolus in these patients with lower-extremity amputation.

CONCLUSION

No clinical objective evidence of pulmonary emboli occurred after placement of an inferior vena caval filter.

What is the paradigm: hospital or home health care for pressure ulcers?

A home health care (HHC) referral should link the patient in a cost-effective fashion to the physician, home care, and instructions regarding ulcer management. Twenty-one patients (mean age, 74.6 years) had stage III pressure ulcers (<100 cm2) and an involved family member at home. Risk and contributing factors included cardiac disease (n = 9), hypertension (n = 14), end-stage renal disease (n = 7), smoking (n = 11), diabetes (n = 8), chronic brain syndrome (n = 14), cerebrovascular accident (n = 5), and above-the-knee amputation (n = 2). Treatment regimens included standard wound care, pressure relief and, where appropriate, culture-specific antibiotics, as well as a rehabilitation program. Home care progressively decreased the frequency of the nurse HHC and physician office visits. Resolution of the pressure ulcer varied from 6 to 32 weeks. Only two patients had progression of their wound and required hospital readmission. The billable fees included: 1) an office visit, $30.00 (medicare reimbursement, $14.00); 2) the HHC nurse visit, $159.00 (medicare reimbursement, $105.00); 3) supplies, $75.00 to $150.00/week (variable reimbursement); 4) hospitalization, $400.00 to $900.00/day; and 5) a chronic-care bed, $400.00 to $750.00/day. HHC, given a responsible support team and an involved family member, was more socially and financially acceptable than an inpatient facility. Intermittent physician visits with HHC proved safe and reliable, with 90 per cent successfully healing their wounds.

Management of vascular prosthetic infections: results of long-term follow-up

An infected vascular prosthesis is a risk to life and limb, with many of the infections insidious in nature. A retrospective analysis with a minimum 49-month follow-up identified 18 patients (mean age, 61.3 years) with culture-positive infections and exposed prosthetic grafts in the infrainguinal region. All patients were managed with muscle flaps. Mean follow-up was 59 months, with a long-term salvage of infected prosthetic grafts in 16 of 18 patients; there was no loss of life or limb. Early, aggressive reconstruction of infected prosthetic grafts using a muscle flap technique saves graft, leg, and patient.

Peripheral arterial occlusion in acute promyelocytic leukemia

A 16-year-old Caucasian teenager developed fatigue, abdominal pain, pneumonia, and subsequently acute vascular occlusion of the left superficial femoral artery. Vascular assessment and heparin therapy lead to bone marrow aspiration and a diagnosis of acute promyelocytic leukemia. Treatment with chemotherapy prevented loss of limb and avoided further vascular surgery. Young patients with acute vascular occlusion require an in-depth assessment including attention to hematological disorders. Clots obtained on thromboembolectomy should be sent for pathological assessment and not discarded, especially in an unusual-age patient for arterial embolus.

Influence of incisional complications on infrainguinal vein bypass graft outcome

Incisional complications following infrainguinal vein bypass remain a formidable challenge to the vascular surgeon. A retrospective analysis of 250 infrainguinal vein bypass grafts (214 patients) was undertaken to identify risk factors for the development of incisional complications and determine the impact of incisional complications on outcome. Incisional complications occurred in 47 (19%) of the bypasses. The mean age was 67.8 years and 155 (62%) of the bypasses were performed in men. The patients were divided into two groups based on the presence or absence of an incisional complication. By univariate analysis, the contributing factors for an incisional complication were: veteran hospital status, dialysis dependence, anemia, obesity, leukocytosis, and hypoalbuminemia (p < 0.05). By multivariate analysis, veteran hospital status, female gender, leukocytosis, and prior ipsilateral bypass were independent risk factors for incisional complications (p < 0.05). The increased incidence of incisional complications in the veteran's hospital group was associated with anemia, leukocytosis, decreased lymphocyte count, and increased incidence of tissue loss (p < 0.05). By life-table analysis, incisional complications did not influence primary patency (p = 0.73), secondary patency (p = 0.91), limb salvage (p = 0.69), or survival (p = 0.92). However, a significant suppurative soft-tissue infection ultimately resulted in a high rate of major amputation.

Erythropoietin therapy improves graft patency with no increased incidence of thrombosis or thrombophlebitis

BACKGROUND

Recombinant human erythropoietin (rHuEPO) for the treatment of severe anemia in patients with end-stage renal disease (ESRD) is suggested to improve rehabilitation and cognitive function. The criticism is the alleged increase in the failure rate of arteriovenous (AV) access grafts and in the incidence of lower-extremity deep venous thrombophlebitis (DVT). This study addressed the longevity of AV grafts and the incidence of DVT.

STUDY DESIGN

We reviewed 481 consecutive patients with ESRD on dialysis with PTFE access grafts, including 173 consecutive patients who were receiving rHuEPO and 308 who were not. rHuEPO was administered during dialysis titrated against the hematocrit to achieve a level of 33% to 38%. The rHuEPO-ESRD group included 173 patients with a mean age of 58 years, including 54% women; 84% of the grafts were in the upper extremity. In the control group of 308 patients, 57% were women. Diabetes and hypertension were controlled in both groups.

RESULTS

Forty-five of 173 rHuEPO patients (26%) experienced graft thrombosis within 1 year. Among 88 episodes of thrombosis, 14 patients experienced multiple episodes. Primary patency was 8.9 months; secondary patency was 11.2 months. In the control population, 95 of 308 patients (31%) experienced graft thrombosis; 27 patients had multiple episodes. Primary patency was 7.8 months and secondary patencywas 9.8 months. The hematocrit improved from a mean of 23% in the control group to 34% in the treated rHuEPO group. Two patients in the control group and one patient receiving rHuEPO experienced DVT in the lower extremity.

CONCLUSIONS

Primary and secondary AV fistula patency rates were improved by 10% with rHuEPO. rHuEPO did not increase DVT.

Venous leg ulcers and the family physician

Family physicians often are the first contact for patients with venous leg ulcerations (VLUs). A random survey of 2,000 family physicians was conducted to determine patterns for diagnosis and treatment of VLUs, including type of leg ulcer (arterial, venous, diabetic), whether compression therapy was ordered, whether a Doppler system was available to aide in diagnosis, and which health care professional ultimately cared for the patient. Of the 325 family physicians who participated, 96% (311/325) see patients with VLUs, averaging 1.5 VLUs per week. Compression therapy is prescribed by 96% of family physicians, and 83% (259/325) refer these patients to other health care professionals. Only 27% (89/325) have a Doppler system in the office to measure the ankle-brachial index (ABI). These findings document for the first time in the United States the large number of patients with VLUs seen by family physicians.

Leg ulceration in the sickle cell patient

BACKGROUND

The purpose of this study was to determine cost of care for leg ulcers in sickle cell patients and suggest an improved modality in ulcer care.

STUDY DESIGN

We performed a retrospective study of a group of sickle cell disease patients with leg ulcers.

RESULTS

Eighteen patients with a leg ulcer (duration: mean, 53.7 months), sickle cell disease, and a mean of 20.7 years of age had various modalities of treatment with the only consistency in healing being a commercial moist-wound dressing.

CONCLUSIONS

There is no consistency in the treatment of the sickle cell patient with a leg ulcer. Treatment with a moist dressing had the best results.

Epidemiology, risk factors, and management of peripheral vascular disease

Peripheral vascular occlusive disease is initiated with a genetic risk factor component compounded by patient-controlled contributions including obesity, diabetes, hypertension, and smoking. Medical management of these factors may delay or obviate surgical intervention. Angiography may be used to perform angioplasty (+/- stents) or to guide various interventional procedures. The major contribution to pre- and post-operative assessment is the noninvasive laboratory.

Wound infection: a physician's perspective

Infection in a wound represents a colony count of 10(5) or greater. Contamination is the presence of many surface organisms. Moist wound healing, not dehydration, protects and prepares the wound for coverage and closure. Relief of pain is a critical factor in achieving healing: a biological or pharmaceutical device can achieve protection and facilitate healing.

Carotid endarterectomy outcome is not affected in patients with a contralateral carotid artery occlusion

BACKGROUND

The purpose of this retrospective patient/control patient study was to determine perioperative risk and long-term benefits of carotid endarterectomy contralateral to an occluded internal carotid artery.

METHODS

Thirty-seven patients undergoing carotid endarterectomy contralateral to an occluded internal carotid artery were each paired with two control group patients (n = 74) undergoing carotid endarterectomy contralateral to a patent internal carotid artery. Patients preferentially underwent electroencephalographic monitoring, selective shunting, and patch angioplasty for vessel closure.

RESULTS

The perioperative rate of stroke or death was 5% (n = 2) in the occluded group and 3% (n = 2) in the control group. Ninety-two percent of the occluded group and 96% of the control patients were stroke-free over a mean follow-up of 23.8 and 27.2 months, respectively. No statistical difference was noted between groups for perioperative rate of stroke or death (P = 0.60), mean stroke-free rates (P = 0.37), stroke rate by life-table analysis (P = 0.33), or survival by life-table analysis (P = 0.43).

CONCLUSIONS

Patients who have carotid endarterectomy performed contralateral to an occluded internal carotid artery showed no difference for perioperative stroke or death, late stroke, or survival.

Impact of diabetes mellitus on infrainguinal bypass grafting

The purpose of this study was to examine the role of diabetes mellitus (DM) in infrainguinal bypass graft outcome. One hundred forty-four patients who underwent 170 infrainguinal bypass grafts from 1990 to 1995 were reviewed retrospectively. Seventy-eight patients (94 bypasses) had DM and were followed for an average of 15.4 months; 13 patients were lost to follow up. The mean age was 68 years; 44 (56.4%) were men. The major indication for intervention was limb salvage for the DM (87/94, 92.6%) and non-DM (56/76, 73.7%) groups. No significant difference was found for perioperative wound complications, hematoma, myocardial infarction, or deep venous thrombosis between the DM and non-DM groups. Early mortalities were three for DM and one for non-DM patients. No significant difference was found between primary patency (p = 0.71), secondary patency (p = 0.32), limb salvage (p = 0.99), and survival (p = 0.72) between DM and non-DM groups. DM patients were more likely to have significant tissue loss (p = 0.009) and a longer hospital stay (p = 0.01). In conclusion, infrainguinal vein bypass grafting can be performed successfully in diabetic patients with comparable patency and limb-salvage rates to those without DM.

Tobacco. Its impact on vascular disease

The role of smoking in vascular disease is multifactorial and complex. Research continues to further elucidate the mechanisms involved and advance treatment options. What remains clear throughout is that smoking cessation has multiple health benefits. In a recent public health projection study of mortality and disability by cause, tobacco use was marked as the potentially largest health problem to be expected in the year 2020. Although smoking cessation is not simple, in the years spanning 1993 to September 1997, 1720 articles were published under the key words "smoking cessation," reflecting the difficulty of this endeavor and lack of a satisfying answer to this health problem. Nonetheless, approaches to patient smoking cessation should be attempted by all physicians. A protocol for physicians to assist patients with smoking cessation from the National Cancer Institute can serve as a general guide (Fig. 3). Some of the programs available to assist patients in smoking cessation are listed in Table 7.

Peripheral neuropathies in diabetes

Peripheral neuropathy in diabetes remains a difficult management dilemma. The clinical manifestations may vary widely. Polyneuropathies develop with increasing duration of disease, and a thorough understanding of the clinical manifestations, including sensory, motor, and autonomic deficiencies, helps guide diagnosis and treatment. A multidisciplinary approach emphasizing preventive care and timely intervention can decrease morbidity significantly and improve the quality of life for the patient. Properly fitting shoes and avoidance of foot trauma are cornerstones of preventive management. Strict control of serum glucose can alter the course of peripheral neuropathies. This control can be accomplished with a strict insulin regimen or pancreatic transplant. Further research is needed to increase knowledge about peripheral neuropathies in diabetes and aid the physician with new treatment options.

Improved coordination: the wound care specialist

Optimal, cost-effective patient care requires the integration of research findings into practice and a continuing assessment of outcomes attained, which cannot be achieved unless care is continuous and multidisciplinary. Well-defined requirements for the education of an advanced practice nurse results in quality and effective wound-care delivery in a cost-effective fashion. The concerns of business and health must be blended to achieve optimal patient care.

Aneurysms of the pancreaticoduodenal arteries: a change in management

Since the first report of an aneurysm involving the pancreaticoduodenal arteries a century ago, only 83 cases have been reported in our collective review of the English literature. Their presentation varies from indistinct abdominal pain to hemorrhagic shock, often making the diagnosis onerous. The mortality rate in this patient group has been significant, and in cases reported since 1980, the mortality rate remains at 17% (7 deaths/42 reported cases). Surgery has been, and continues to be, the cornerstone of therapy, with an incumbent mortality rate of 19% (5 deaths/26 patients treated surgically since 1980). This case report and 100-year review of the literature describes the causes, natural history, and historic management of pancreaticoduodenal artery aneurysms. Most importantly, it demonstrates the use of angiographic embolization in the definitive management of these aneurysms with no mortality.

Arterial insufficiency and vasculitides

Multiple conditions, such as peripheral atherosclerosis, systemic lupus erythematosus, polyarteritis nodosa, and dermatomyositis, predispose a patient to arterial insufficiency of the lower extremities and subsequent formation of nonhealing wounds. This article will review the pathophysiology of these conditions, identify the unique physical characteristics of each, and describe the diagnostic tests needed for a complete evaluation. The management of lower-extremity ulcers complicated by arterial insufficiency will be reviewed; emphasis is also placed on treating the underlying condition in an effort to promote both healing of existing wounds and the prevention of further ulceration.

Sequential biannual prevalence studies of pressure ulcers at Allegheny-Hahnemann University Hospital

To assess the prevalence, documentation and care of pressure ulcers, and the effect of teaching and prevention strategies in a 750-bed university hospital, one-day studies were conducted in 1993, 1995, and 1997. Data gathered was used to evaluate areas in need of improvement and find cost-effective ways to reduce the prevalence of pressure ulcers. The overall prevalence of ulcers decreased from 18 percent in 1993 to 10 percent in 1995 and 1997. The prevalence of nosocomial ulcers decreased from 14 percent in 1993 to 8 percent in 1995 and 6 percent in 1997. The number of nutritional consults increased from 54 percent in 1993 to 67 percent in 1997, and more than half of all patients tested had serum albumin levels < 3.5 mg/dL. Skin assessments upon admission were completed in the majority of patients. While ulcer documentation was less than adequate for the majority of patients in 1993 and 1997, care measures, e.g., placement of patients on specialty beds or mattresses and use of dressings that provide a moist environment, improved considerably. The results of this study indicate that system-wide educational efforts aimed at all levels of patient care providers, and multi-specialty prevention and care efforts can reduce the prevalence of pressure ulcers.

Does renal failure influence infrainguinal bypass graft outcome?

The purpose of this study is to determine the role of renal failure (RF) in infrainguinal bypass graft outcome. From 1990 through 1996, 206 patients underwent 241 infrainguinal bypass grafts at two institutions. Thirty-three RF patients (42 bypasses) had a mean follow-up of 14.0 months and a mean age of 67.7 years, and 21 (64%) were male. Risk factors included hypertension (100%), diabetes (81.8%), and cardiac disease (75.8%). RF patients included 20 with end-stage renal disease (ESRD) and 14 with renal insufficiency (RI). One patient had RI during his first bypass and ESRD for his subsequent bypass. The major operative indication was limb salvage (90.5%). Total perioperative morbidity for ESRD was significantly higher than for RI and non-RF groups (P = 0.019). Early mortalities occurred in three ESRD, no RI, and seven non-RF patients. Life table analysis demonstrated no significant difference between primary patency (P = 0.56), secondary patency (P = 0.96), and limb salvage (P = 0.69) between ESRD and non-RF groups. However, there was an overall decreased survival rate in the ESRD group (P < 0.01). In conclusion, infrainguinal vein bypass grafting can be successfully performed in RF patients with comparable patency and limb salvage rates and therefore improve quality of life. However, perioperative morbidity was higher in ESRD and survival was significantly shorter for RF than for non-RF patients.

Sociology of care in patients with severe peripheral vascular disease

Peripheral vascular disease (PVD) remains a leading cause of limb amputation, resulting in a significant morbidity and disability. This study was undertaken to evaluate whether earlier referral of the patients with severe limb-threatening PVD to a vascular surgeon could result in a higher limb-salvage rate. Seventy-one consecutive patients, 48 men and 23 women, with mean ages of 67.1 and 70.4 years, respectively, were studied; there were 64 blacks (42 men, 22 women). Risk factors included smoking (39 men, 20 women) and diabetes mellitus (31 men, 11 women). The delay in seeking medical attention in patients with rest pain was 9 to 24 weeks (mean, 14.2), and with nonhealing ulcers the delay was 4 to 20 weeks (mean, 6.7). An additional delay of 11.7 weeks was noted if the patient was seen by a primary-care physician, and only 4 weeks if the patient was seen in the Emergency Department. Ten primary amputations were performed; 61 patients underwent limb-salvaging revascularization procedures, with a success rate of 87 per cent; 8 patients had below-the-knee amputation as a result of failed bypass. Delay in referral of patients with severe PVD can cause an increase in limb loss.

Safety of carotid endarterectomy associated with small intracranial aneurysms

BACKGROUND

The incidence and outcome of combined carotid artery disease and intracranial aneurysm (ICA) are not well reported.

METHODS

Ten patients with combined disease, ICA and symptomatic carotid artery disease, were identified in 209 consecutive angiograms. Five men and five women with a mean age of 68 years and the risk factors of diabetes, hypertension, smoking, cardiac disease, peripheral vascular disease, and hypercholesterolemia formed the basis for this study.

RESULTS

Five patients with carotid endarterectomy (CEA) and arterial aneurysms less than 5 mm and five with carotid stenosis and ICA less than 6 mm were treated with Coumadin; one with combined disease left the hospital without treatment; and one with combined disease died preoperatively of a myocardial infarction. One patient with a 2 cm x 3 cm ICA and carotid had both operated on successfully.

CONCLUSIONS

In this group of patients, CEAs were done safely in patients with ICAs less than 6 mm.

Options for diabetic patients with chronic heel ulcers

The presence of a heel ulcer in the diabetic patient is usually due to neuropathy, vasculopathy, or both. Diagnostic testing including noninvasive assessment by nerve conduction velocity and Doppler pressure measurements can provide the basis for subsequent treatment. The diagnosis of osteomyelitis is assisted by plain radiographs, isotope definition, and/or magnetic resonance imaging (MRI). The loss of the calcaneus may mean loss of the functioning foot. Reconstructive arterial surgery for heel lesions in the diabetic patient has limited success. Prevention and local wound care, along with patient education, will result in limb salvage and the prevention of disability.

Toe amputation in the diabetic patient

BACKGROUND

We considered whether it is more practical to amputate the toe of a diabetic patient with osteomyelitis and good circulation or to treat the patient with antibiotics for a prolonged period.

METHODS

We undertook a retrospective study of 141 diabetic patients who had undergone a toe-ray amputation for proven or documented osteomyelitis.

RESULTS

The mean ankle/brachial index of all patients was 0.81 (range, 0.68 to 1.14); the mean functional days lost on antibiotic therapy was 39 (range, 7 to 84 days). The cost of 6 to 8 weeks of preoperative antibiotic therapy was $900 to $2240 (mean, $1440).

CONCLUSIONS

Diabetic patients with good circulation and osteomyelitis of the toe may benefit from prompt toe amputation.