The Bagautdinov dressing method: negative pressure wound therapy in a patient with an allergy to acrylate adhesive.

Current embodiments of negative pressure wound therapy (NPWT) create a hermetically sealed chamber at the surface of the body using polyurethane foam connected to a vacuum pump, which is then covered by a flexible adhesive drape. Commercially available NPWT systems routinely use flexible polyethylene films that have a sticky side, coated with the same acrylate adhesives used in other medical devices such as ECG leads and grounding pads. Severe reactions to the acrylate adhesives in these other devices, although uncommon, have been reported. We describe the case of a 63-year-old woman with an intractable leg ulcer resulting from external-beam radiotherapy (XRT). Treatment with a standard commercial NPWT system induced severe inflammation of the skin in direct contact with drape adhesive. We successfully administered prolonged, outpatient NPWT to the patient using an alternative method (first described by Bagautdinov in 1986), using plain polyethylene film and petrolatum. The necessary hermetic seal is achieved by smearing the skin with petrolatum before applying the polyethylene film and activating the vacuum pump. The Bagautdinov method is a practical solution to the problem of adapting NPWT to patients with contact sensitivity or skin tears related to the adhesive compounds in the flexible drapes. Its use of a circumferential elastic wrap to maintain constant pressure on the seal probably limits the Bagautdinov technique to the extremities.

Postintervention Patency: A Comparison of Stenting versus Patch Angioplasty for Dysfunctional Hemodialysis Access Sites.

BACKGROUND: Arteriovenous access dysfunction is commonly caused by venous outflow stenosis, leading to thrombosis of the conduit. Given that there are limited lifetime hemodialysis access sites, the preservation of existing sites through novel means is of high priority. This study compares the efficacy of balloon angioplasty and stent placement to surgical patch angioplasty for upper arm (brachium) thrombosed or dysfunctional hemodialysis access sites in a group of patients at a single institution. METHODS: Using the operating room log and electronic medical record system, we retrospectively examined the outcomes of 52 consecutive patients (3 were lost to follow-up), who had either stent placement (34 patients) or patch angioplasty (15 patients) for hemodialysis access salvage to calculate postintervention patency. RESULTS: Initial postinterventional patency (PIP1) for patch angioplasty compared with stent placement was not statistically significant at any time during a mean 6-month follow-up (60% vs. 67.65% at 1 month, 33.33% vs. 41.18% at 3 months, and 13.33% vs. 17.65% at 6 months, respectively; P = 0.75). Patency after secondary reintervention (PIP2) was longer for patients who had stent placement as the initial intervention (n = 15) than patients who had patch angioplasty (n = 5; 100% vs. 80% at 1 month, 66.68% vs. 80% at 3 months, and 46.67% vs. 40% at 6 months, respectively), but again there was no statistically significant difference between the 2 groups (P = 0.84). At last, the initial PIP1 of arteriovenous fistula (AVF) and arteriovenous graft (AVG) salvaged before occlusion was significantly different from that of occluded access sites (40% vs. 10% at 6 months, P = 0.024). CONCLUSIONS: Our data suggest that AVF had a longer postinterventional primary patency than AVG though the difference did not reach statistical significance. Stents extended PIP1 for the thrombosed or failing arteriovenous access longer than patch angioplasty, but the difference was not statistically significant. Patency is longer if intervention is made before graft thrombosis. Our data also indicate better prolongation of patency with a second reintervention (PIP2) if the first intervention was a stent placement. Patch angioplasty appears to be a less attractive alternative for correction of venous outflow stenosis given the more invasive and occasionally technically difficult procedure.

Effects of cilostazol on arterial wound healing: a retrospective analysis.

BACKGROUND: The vasodilator cilostazol (Pletal(®)), a phosphodiesterase-3 inhibitor, is approved in the United States for treatment of intermittent claudication. This study was aimed at evaluating its efficacy as an adjunct in the management of arterial ulceration. METHODS: The clinical records of patients treated with cilostazol from 2000 to 2010 at one institution were obtained. Of the 561 patients treated with cilostazol, we identified 82 (101 limbs) who started on therapy only after wounds were present and whose records were sufficient to assess healing. Only if all wounds in a limb completely healed without intervening arterial reconstruction, amputation, primary closure, or skin grafting, the limb was deemed healed with the assistance of cilostazol. With bilateral involvement, both limbs had to heal for the patient to be judged healed. Subjects who were lost to follow-up, died, or underwent surgical interventions other than debridement were deemed failures. Age, weight, height, body mass index (BMI), creatinine, diabetes, insulin therapy, hemodialysis, smoking history, congestive heart failure, cilostazol dose, and length of therapy were compared, as well as, the number of wounds, size of largest wound, chronicity, ankle-brachial index, the presence of exposed bone/tendon/joint, or the presence of gangrene. RESULTS: Overall 30 of 82 patients (36.6%) and 41 of 101 (40.6%) limbs were deemed healed without surgical intervention or revascularization (open or endovascular). When 9 limbs that healed after skin grafts (n = 2) or foot-sparing amputations (n = 7) but without revascularization were considered, the overall rate of lower extremity limb salvage was 50.5%. Demographic characteristics were similar in the 2 groups except healed patients tended to be taller and weigh more but had similar BMI. The incidence of diabetes was higher in nonhealed limbs (73.3% vs. 50.0%, P = 0.0587). Gangrene was less common in healed patients (22.6% vs. 49.1%, P = 0.059) and healed limbs (22.0% vs. 48.3%, P = 0.027). Most subjects received 200 mg of cilostazol daily (healed:177 ± 53 mg vs. nonhealed: 172 ± 47 mg). Mean length of therapy in healed patients was 278 ± 302 days compared with 108 ± 129 days in nonhealed subjects before discontinuation of drug therapy or surgery, death, or loss to follow-up intervened. CONCLUSIONS: The observed limb healing rate with cilostazol compares favorably to the ~20% rate observed in subjects treated with placebo in multicenter trials of another vasodilator, iloprost. Although gangrene and diabetes correlate with lower prospects for healing, our data suggest that cilostazol helps promote healing of wounds when arterial insufficiency is present.

Surveillance computed tomographic arteriogram does not change management before 3 years in patients who have a normal post-EVAR study.

BACKGROUND: Standard surveillance after endovascular abdominal aortic aneurysm repair (EVAR) consists of periodic computed tomographic arteriographies (CTAs) usually performed at postoperative months 1, 6, and 12, and then annually. This imaging regimen is expensive and exposes patients to the hazards of radiation and intravenous contrast. We hypothesized that a normal 1-month CTA after EVAR with no endoleak or other significant abnormality predicts a low rate of future complications, which would justify a reduction in frequency of subsequent CTAs. METHODS: We identified 106 consecutive patients who underwent EVAR at a single hospital from 2003 to 2010 and reviewed all their CTAs. Fifteen patients for whom we could not review a postoperative CTA were excluded. Of the remaining 91 patients, 70 (76.9%) had no abnormality on their CTA at 1 month after EVAR. The medical records of these 70 patients were analyzed for subsequent complications and interventions related to EVAR. RESULTS: The mean patient follow-up was 3.4 ± 2.1 years. Five of the 70 (7.1%) patients with a normal post-EVAR CTA developed late complications consisting of 1 type I endoleak, 3 type II endoleaks, and 1 case of endotension. Only the type I endoleak and one of the type II endoleaks met criteria for intervention, and in both cases, the endoleaks were discovered >3 years after EVAR. Log-rank test showed a statistically significant increased freedom from aneurysm sac expansion in patients with a normal compared with an abnormal 1-month CTA (P < 0.001). CONCLUSIONS: For patients who have a normal CTA with no endoleak 1 month after EVAR, it is reasonable to consider less-frequent CTA surveillance because no significant complications requiring intervention occurred before 3 years. This would decrease unnecessary CTAs and health care expenditures as well as minimize patient exposure to radiation and intravenous contrast.

Hyperspectral image measurements of skin hemoglobin compared with transcutaneous PO2 measurements.

BACKGROUND: Objective measurements of skin blood flow would have predictive value in assessing the potential for wound healing. In this study, we evaluated the relationship between transcutaneous PO(2) (tcPO(2)) measurements and hyperspectral reflectance spectroscopy measurements of oxygenated hemoglobin (OxyHgb), deoxygenated hemoglobin (DeOxyHgb), total hemoglobin (Sum = OxyHgb + DeOxyHgb), and hemoglobin saturation (Sat = 100 × OxyHgb/Sum). The effect of varying tcPO(2) probe temperatures (37 °C, 41 °C, and 45 °C) was also assessed. METHODS: A Hypermed Oxy-Vu system was used for hyperspectral imaging, with measurements performed 2 minutes after removing tcPO(2) probes (Radiometer). Twenty-three sections of foot or wrist skin in four healthy volunteers were measured at 37 °C, 41 °C, and 45 °C using both modalities. RESULTS: TcPO(2) at 37 °C was 23.1 ± 24.8 mm Hg, increasing to 63.0 ± 27.3 mm Hg at 45 °C. OxyHgb levels increased from 52.4 ± 25.4 at 37 °C to 101.3 ± 23.8 at 45 °C. Linear regression analysis of the HSI data at 37 °C showed a positive correlation between tcPO(2) and OxyHgb (r(2) = 0.35, P = 0.003), tcPO(2) and DeOxyHgb (r(2) = 0.63, P < 0.0001), and tcPO(2) and Sum (r(2) = 0.60, P < 0.0001), but not Sat (r(2) = 0.001, P = 0.92). As the probe temperature increased, the correlations of tcPO(2) with OxyHgb, DeoxyHgb, and Sum became progressively much weaker. CONCLUSION: A marked increase in the HSI measurements of OxyHgb in skin exposed to heated tcPO(2) probes was observed, with tcPO(2), Sat, and Sum measurements also observed to increase with temperature. These measurements were influenced by heat inducing vasodilatation in the superficial skin layers. HSI measurements may be clinically useful for measuring wound healing potential, as they correlate with tcPO(2) levels under normal physiological conditions.

Hyperspectral imaging and ankle: brachial indices in peripheral arterial disease.

BACKGROUND: To evaluate the correlation between ankle:brachial indices (ABI) and visible light reflectance spectroscopy hyperspectral imaging (HSI) determinations of oxygenated and deoxygenated hemoglobin (oxyHgb and deoxyHgb) levels in the skin of the distal lower extremity. This is a prospective, open, comparator trial which took place at the Vascular laboratory of a Veterans Administration Hospital in Long Beach, USA. Fifty-eight patients (85 limbs) were referred for routine vascular laboratory studies including ABI had concomitant HSI. Limbs with noncompressible pedal signals were excluded from the analysis. METHODS: ABI was determined with continuous wave Doppler ultrasound and leg blood pressure cuffs. A commercial HSI system (Oxu-Vu(R), Hypermed, Inc.) was used to measure oxyHgb, deoxyHgb, and percent oxygenated hemoglobin (%oxyHgb) in the dorsum of the foot and ankle. HSI measurements of volar forearm skin were also obtained to normalize the lower extremity HSI measurements in a manner comparable with ABI. RESULTS: For purposes of comparison, data sets were divided into 3 groups: ABI > 0.9 (n = 53), 0.45 < ABI < 0.9 (n = 22), and ABI < 0.45 (n = 10). There were no significant differences between oxgyHgb, %oxyHgb, normalized oxyHgb, and normalized %oxyHgb when means values for these parameters were compared between the three groups based on unpaired t test statistics. CONCLUSION: The lack of a correlation between HSI measurements and ABI is consistent with previous observations that in moderate peripheral arterial disease skin perfusion is maintained at normal levels and in critical ischemia paradoxical increased flow may be present. Although the current study failed to show a clinically useful correlation between HSI measurements of oxyHgb levels, further evaluation of this novel technology is warranted.

Accuracy of a foot temperature monitoring mat for predicting diabetic foot ulcers in patients with recent wounds or partial foot amputation.

AIMS: To assess the accuracy of once-daily foot temperature monitoring for predicting foot ulceration in diabetic patients with recent wounds and partial foot amputation, complications previously perceived as challenging. METHODS: We completed a planned analysis of existing data from a recent study in 129 participants with a previously-healed diabetic foot ulcer. We considered four cohorts: all participants, participants with partial foot amputation, participants with a recent wound, and participants without partial foot amputation and without a recent wound. We reported the prediction specificity, lead time, and annualized alert frequency in each cohort at maximum sensitivity. We assessed the two potentially challenging cohorts for non-inferior accuracy relative to the control cohort using Delong's method. RESULTS: We report non-inferior predictive accuracy in each of the two potentially-challenging cohorts relative to the control cohort (⍺ < 0.05). The alert lead time was similar across these cohorts, ranging from 33 to 42 days. CONCLUSIONS: Once-daily foot temperature monitoring is no less accurate for predicting foot ulceration in those with recent wounds and partial foot amputations than in those without these complications. These results support expanded practice of once-daily foot temperature monitoring, which may result in improved patient outcomes and reduced healthcare resource utilization.

Effect of optically modified polyethylene terephthalate fiber socks on chronic foot pain.

BACKGROUND: Increasing experimental and clinical evidence suggests that illumination of the skin with relatively low intensity light may lead to therapeutic results such as reduced pain or improved wound healing. The goal of this study was to evaluate prospectively whether socks made from polyethylene terephthalate (PET) incorporating optically active particles (Celliant) ameliorates chronic foot pain resulting from diabetic neuropathy or other disorders. Such optically modified fiber is thought to modify the illumination of the skin in the visible and infrared portions of the spectrum, and consequently reduce pain. METHODS: A double-blind, randomized trial with 55 subjects (38 men, 17 women) enrolled (average age 59.7 +/- 11.9 years), 26 with diabetic neuropathy and 29 with other pain etiologies. Subjects twice completed the Visual Analogue Scale (VAS), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ), and SF-36 a week apart (W(1+2)) before receiving either control or Celliant socks. The same questionnaires were answered again one and two weeks (W(3+4)) later. The questionnaires provided nine scores for analyzing pain reduction: one VAS score, two BPI scores, five MPQ scores, and the bodily pain score on the SF-36. Mean W(1+2) and W(3+4) scores were compared to measure pain reduction. RESULTS: More pain reduction was reported by Celliant subjects for 8 of the 9 pain questions employed, with a significant (p = 0.043) difference between controls and Celliant for McGill question III. In neuropathic subjects, Celliant caused more pain reduction in 6 of the 9 questions, but not significantly. In non-neuropathic subjects 8 of 9 questions showed more pain reduction with the Celliant socks. CONCLUSION: Socks with optically modified PET (Celliant) appear to have a beneficial impact on chronic foot pain. The mechanism could be related to the effects seen with illumination of tissues with visible and infrared light. TRIAL REGISTRATION: ClinicalTrials.gov NCT00458497.

Effect of Shirts with 42% Celliant™ Fiber on tcPO2 Levels and Grip Strength in Healthy Subjects: A Placebo-controlled Clinical Trial.

Celliant™ fabric contains quartz, silicon oxide and titanium oxide particles embedded into polymer fibers. Garments woven with Celliant™ yarns can be activated by body heat (conduction, convection and radiation) and remit the energy as far infrared radiation (FIR) back into the body. Wearing Celliant garments has been shown to increase blood flow and oxygen levels in the skin. In the present study we recruited twenty-four healthy volunteers (18-60 years of age) to wear a placebo shirt for 90 minutes, and after a 15-minute break, to wear a real Celliant shirt for 90 minutes. The mean transcutaneous oxygen (tcPO2) measured over two sites (biceps and abdomen) was significantly increased at 3 time points (30, 60, and 90 minutes) by between 5-8% (P<0.05) in Celliant vs. placebo. The mean grip strength in the dominant hand measured at 90 minutes was 12.44% higher after wearing Celliant vs. after placebo (p=0.0002). There was a small but significant increase in systolic blood pressure (113.71 vs. 109.38; p=0.02) but no statistically significant changes in diastolic or mean blood pressure, heart rate, or skin temperature. These data provide more evidence of the physiological effects of FIR emitting garments and suggest they could be used for athletic training and recovery.

Immediate repair compared with surveillance of small abdominal aortic aneurysms.

BACKGROUND: Whether elective surgical repair of small abdominal aortic aneurysms improves survival remains controversial. METHODS: We randomly assigned patients 50 to 79 years old with abdominal aortic aneurysms of 4.0 to 5.4 cm in diameter who did not have high surgical risk to undergo immediate open surgical repair of the aneurysm or to undergo surveillance by means of ultrasonography or computed tomography every six months with repair reserved for aneurysms that became symptomatic or enlarged to 5.5 cm. Follow-up ranged from 3.5 to 8.0 years (mean, 4.9). RESULTS: A total of 569 patients were randomly assigned to immediate repair and 567 to surveillance. By the end of the study, aneurysm repair had been performed in 92.6 percent of the patients in the immediate-repair group and 61.6 percent of those in the surveillance group. The rate of death from any cause, the primary outcome, was not significantly different in the two groups (relative risk in the immediate-repair group as compared with the surveillance group, 1.21; 95 percent confidence interval, 0.95 to 1.54). Trends in survival did not favor immediate repair in any of the prespecified subgroups defined by age or diameter of aneurysm at entry. These findings were obtained despite a low total operative mortality of 2.7 percent in the immediate-repair group. There was also no reduction in the rate of death related to abdominal aortic aneurysm in the immediate-repair group (3.0 percent) as compared with the surveillance group (2.6 percent). Eleven patients in the surveillance group had rupture of abdominal aortic aneurysms (0.6 percent per year), resulting in seven deaths. The rate of hospitalization related to abdominal aortic aneurysm was 39 percent lower in the surveillance group. CONCLUSIONS: Survival is not improved by elective repair of abdominal aortic aneurysms smaller than 5.5 cm, even when operative mortality is low.

Feasibility and Efficacy of a Smart Mat Technology to Predict Development of Diabetic Plantar Ulcers.

OBJECTIVE: We conducted a multicenter evaluation of a novel remote foot-temperature monitoring system to characterize its accuracy for predicting impending diabetic foot ulcers (DFU) in a cohort of patients with diabetes with previously healed DFU. RESEARCH DESIGN AND METHODS: We enrolled 132 participants with diabetes and prior DFU in this 34-week cohort study to evaluate a remote foot-temperature monitoring system (ClinicalTrials.gov Identifier NCT02647346). The study device was a wireless daily-use thermometric foot mat to assess plantar temperature asymmetries. The primary outcome of interest was development of nonacute plantar DFU, and the primary efficacy analysis was the accuracy of the study device for predicting the occurrence of DFU over several temperature asymmetry thresholds. RESULTS: Of the 129 participants who contributed evaluable data to the study, a total of 37 (28.7%) presented with 53 DFU (0.62 DFU/participant/year). At an asymmetry of 2.22°C, the standard threshold used in previous studies, the system correctly identified 97% of observed DFU, with an average lead time of 37 days and a false-positive rate of 57%. Increasing the temperature threshold to 3.20°C decreased sensitivity to 70% but similarly reduced the false-positive rate to 32% with approximately the same lead time of 35 days. Approximately 86% of the cohort used the system at least 3 days a week on average over the study. CONCLUSIONS: Given the encouraging study results and the significant burden of DFU, use of this mat may result in significant reductions in morbidity, mortality, and resource utilization.

Negative pressure wound therapy with off-the-shelf components.

BACKGROUND: The KCI Wound VAC system (Kinetic Concepts, Inc, San Antonio, TX) for providing negative-pressure therapy for wounds is expensive and may not be available for patients without insurance. We have examined the feasibility of using off-the-shelf components to provide comparable negative pressure therapy at less cost. METHODS: Adhesive iodine-impregnated drape, a flat Jackson-Pratt drain (Cardinal Health, McGaw Park, IL), and foam prep sponges stapled together are used to assemble a dressing connected to wall suction (negative 75-100 mm Hg) to create negative pressure wound therapy that is relatively inexpensive (<60 US dollars component cost). RESULTS: We have used this system in more than 40 cases with results that seem comparable to the commercial system and have not seen bleeding or other complications. CONCLUSION: Off-the-shelf components can be safely employed to provide effective negative pressure therapy for wounds and skin grafts.

Transmetatarsal amputation: predictors of healing.

The objective of this study is to determine the predictors of healing after transmetatarsal amputations (TMA) and factors leading to a higher level of amputation. A total of 33 TMA was performed in 31 patients during the 5 years between January 2000 and Jul 2005. All patients were men between the ages of 44 and 82 years (mean, 68 years). The mean follow-up period was 36 months (range, 1-65 months). Twelve (40%) TMA required a subsequent higher level of amputation. Seventeen (57%) TMA were successful. The average time until further proximal amputation after TMA was 3.5 months. Risk factors for subsequent higher amputation by univariate analysis included infrapopliteal arterial occlusion (P < 0.05), tobacco smoking greater than 20 years (P < 0.05), and further TMA debridement (P < 0.05). Upon multivariate analysis, only patients undergoing further TMA debridement were at risk for TMA failure (P = 0.01). The difference in ankle-to-brachial pressure ratio (ABI) between the higher amputation group (ABI = 0.51) and the successful TMA group (ABI = 0.54) was not significant. There were no perioperative deaths after TMA. Five (18%) deaths occurred at a mean of 8.2 months after the TMA. In patients who are walking preoperatively, aggressive TMA is warranted in an attempt to maintain ambulation, recognizing that requirement for further debridement, smoking history, and infrapopliteal occlusion may be predictors of nonhealing and subsequent higher amputation.

Resistance within hemodialysis shunts predicts patency.

The authors examined the relationship between patency after thrombectomy of clotted dialysis grafts and intraoperative measurements of flow (Q), pressure gradient (PGR), and longitudinal resistance (RL). Eighteen thrombosed arteriovenous (AV) grafts underwent 21 thrombectomies. Pressures at arterial (P1) and venous (P2) ends of the AV grafts were determined with 22-gauge catheters and standard transducers; flow was measured with transit-time probes; arithmetic averaging of waveforms was used to compute mean Q, PGR, and RL. Kaplan-Meier patency curves were analyzed by using log rank methods. Mean patency for all grafts was 164 +/-152 days. For each variable, the 21 measurements were split and the patency curve for the grafts with the 11 lowest value grafts was compared to the curve representing the 10 highest value grafts. The difference between high RL versus low RL patency curves was significant with high-resistance grafts having a median patency of 55 days and low-resistance grafts having a median patency greater than 151 days (p = 0.0089). In contrast, the high Q group median patency was 151 days versus 174 days for the low Q group (p = 0.86). Median patency for the low PGR group was 115 days compared to 62 days for the high PGR group (p = 0.162). Longitudinal resistance within AV grafts, but not flow or pressure gradient, showed a significant correlation with patency after thrombectomy. Increased resistance to flow within AV grafts appears to be an important factor affecting the propensity of dialysis grafts to thrombose.

Meckel's diverticulitis: a rare etiology of an acute abdomen during pregnancy.

Perforated Meckel's diverticulum (MD) is a rare complication of pregnancy. Its diagnosis, however, must be considered in all cases of intra-abdominal disease, as its presentation is similar to appendicitis. Prompt diagnosis and appropriate treatment is imperative in these cases due to the high rate of perforation leading to fetal and maternal morbidity and mortality. The usual lesion affecting a patient with MD and a review of the literature on other unusual causes of an acute abdomen in pregnancy is presented in the following report.

Comparison of CT and catheter arteriography for evaluation of peripheral arterial disease.

Computed tomographic arteriography (CTA) has emerged as a promising technique for less invasive imaging of the lower extremity arteries. The aim of this study was to determine the concordance between CTA and catheter arteriography (CA) in patients with peripheral arterial disease (PAD). Twenty-five patients underwent both CTA and CA, and each set of images was interpreted independently by 3 readers. The infrarenal arteries were divided into 16 segments, and each segment was scored as: 1 = stenosis <50%; 2 = 50-99% stenosis; 3 = occlusion. Modal scores from 3 readers were used to compare results for each segment, with CA assumed to represent true arterial anatomy. Agreement between CTA and CA readings was defined as: concordance (modal scores were identical); moderate discrepancy (MD) (modal scores differed by 1); or severe discrepancy (SD) (modal scores differed by 2). In total, 718 segments were assessed by both CTA and CA. For all segments, the sensitivity and specificity of CTA for <50% stenosis was 86% and 90%; for 50-99% stenosis, sensitivity and specificity were 79% and 89%; and for occlusion, 85% and 98%. Above-knee (AK) CTA scores had slightly better concordance of 86.1% than below-knee (BK) readings (82.3%) (p = 0.104). Severe discrepancies between AK CTA and CA scores were observed in 1.8% of segments compared to 5.4% of BK segments (p = 0.038). Poor CTA image quality was the cause in 20% of AK segments and 28% of BK segments. Poor CA image quality was the cause in 8% of AK and 7% of BK discrepancies. Registration disagreement (stenosis observed in a level in 1 study attributed to a different level in the other) accounted for 18% of AK and 17% of BK discrepancies. In 54% of AK and 48% of BK discrepancies, neither image quality nor registration errors were identified, indicating that inherent differences in the depiction of stenosis by CA and CTA were responsible. When discrepancies caused by registration error were excluded, SD observed in BK segments (4.0%) remained significantly higher than in AK segments (1.25%) (p = 0.029), and poor CTA quality image was the most common cause (76%) of severe BK discrepancies. In AK discrepancies without an identifiable technical cause, CTA uniformly showed more stenosis, suggesting greater CTA diagnostic precision in larger vessels. In general, agreement between CTA and CA was moderately good. Compared to CA, CTA may be better at depicting stenosis in large, proximal vessels owing to the superior accuracy of cross-sectional images in the measurement of stenosis. There appeared to be poorer CT resolution and higher frequency of severe discrepancies between CTA and CA in BK arteries.

Less Than Total Excision of Infected Prosthetic PTFE Graft Does Not Increase the Risk of Reinfection.

BACKGROUND: Traditional treatment of infected polytetrafluoroethylene (PTFE) grafts consist of removal of the entire prosthesis. Closure of the native vessels may compromise vascular patency. We examined the outcomes for patients in whom a PTFE remnant of an infected graft was retained on the vessel. METHODS: We reviewed the operating room log from 2000 to 2011 and identified all patients who had partial removal of an infected PTFE graft used for hemodialysis or peripheral bypass. These patients were examined for subsequent complications. RESULTS: Twenty-seven patients underwent 30 partial graft excisions with mean follow-up of 27 months. A total of 17% (5 of 30) of the partial graft resection procedures resulted in complications. Of 48 total remnants left behind at the arterial or venous anastomoses, reinfection occurred in 15%. CONCLUSIONS: Leaving a well-incorporated small 1-to 5-mm PTFE remnant at the arterial or venous anastomoses can be performed safely with a low risk of complications.

Reducing the noneducational and nonclinical workload of the surgical resident; defining the role of the health technician.

PURPOSE: Recent controversy over excessive resident work hours has prompted surgical educators and program directors to search for more efficient methods to limit the nonclinical and noneducational workload of surgical residents. Health technicians were employed at a large Veteran's Administration Medical Center to allow residents more time for direct patient care in the clinics and wards and in educational activities. METHODS: In a two-week period, daily data cards were collected from each intern and health technician identifying total hours spent in work, operations, clinics, and conferences. Each intern recorded the number and type of tasks performed and those tasks assigned to the health technician. The number and type of task performed were tabulated and averaged for each health technician and physician. RESULTS: Each intern (n = 3) and health technician (n = 8) completed 100% of the required data forms. In a control survey, each intern worked a mean of 16.9 hours per weekday and 5.0 hours per weekend day. With the addition of the health technicians, interns worked 12.9 hours per weekday and 6.8 hours per weekend day (when the health technicians were not present). Following the addition of the health technicians, resident time in the operating room increased from 3.3 hours per week to 9.8 hours per week. Each health technician aided the intern by performing an average of 20.25 tasks per day. CONCLUSIONS: This study shows that health technicians can be effective in reducing the overall hours and workload of surgical residents and increasing time spent in the operating room. Consideration should be given to including the health technician as integral members of the health care team in the teaching hospital.

Increased endovascular interventions decrease the rate of lower limb artery bypass operations without an increase in major amputation rate.

Progression of peripheral vascular disease may lead to major amputations. We sought to understand whether more frequent endovascular angioplasty and stenting in patients with limb-threatening ischemia would affect the number of major amputations. We retrospectively reviewed the effects of implementing more frequent endovascular intervention for the 4 years 2003-2006 at the Veterans Affairs Medical Center in Long Beach, California. During this interval angioplasty became the preferred method for the treatment of infrainguinal vascular disease. Open bypass procedures were performed for patients with limb-threatening ischemia and extensive lesions that could not be treated by angioplasty. Patients were on average 68 +/- 1 years, and 96% were male. The patients were 45% active smokers, with 43% diabetics. There was 0% 30-day mortality for both groups over the 4 years. the number of below-the-knee, above-the-knee, and transmetatarsal amputations for fiscal years 2003, 2004, 2005, and 2006 were, 42, 50, 62, and 41, respectively. Concurrently, there has been a reduction in open femoral to popliteal or trifurcation vessel bypasses with 37, 43, 28, and 14 procedures for 2003, 2004, 2005, and 2006. Angioplasty and stenting increased from 12, 12, 24, to 59 over the same period. Patients who had a femoral to distal bypass were more likely to have an amputation than those undergoing angioplasty (odds ratio = 4.2, 95% confidence interval 1.6-11.5) for those with at least 1 year of follow-up, likely due to these patients having more severe disease. Increasing the frequency of angioplasty for infrainguinal vascular lesions did not increase the number of major lower extremity amputations in our stable patient population.

Renal function after elective infrarenal aortic aneurysm repair in patients with pelvic kidneys.

Pelvic kidneys complicate aortic reconstructions because of increased risk of renal ischemia. Strategies for protection include shunting, cooling, and reliance on collaterals. A review identified two congenital pelvic kidney (not solitary) and five transplanted kidney patients who underwent elective abdominal aortic aneurysm repair. For congenital pelvic kidneys, topical cooling was used in one patient while no preservation was performed for the other patient. Three transplanted kidney patients were shunted, and one had endovascular repair. Postoperative creatinine values were compared to preoperative values. The two congenital pelvic kidney patients had no significant elevation of creatinine postoperatively. The transplanted kidney patient who underwent endovascular repair had no increase in creatinine postoperatively. All transplanted kidney patients who had open repair had significant but transient increase in creatinine postoperatively. Three patients who were shunted intraoperatively had normalization of creatinine. The patient who had persistent elevation of creatinine at discharge was not shunted. Aortorenal shunting or endovascular repair in transplanted pelvic kidney patients maintains renal function. For patients with congenital pelvic kidneys and adequate collaterals, cooling and collateral perfusion is usually sufficient. Though experience is limited, endovascular repair is likely to be superior to open repair in minimizing renal ischemia.