Treatment of superficial and perforator reflux and deep venous stenosis improves healing of chronic venous leg ulcers.

OBJECTIVE: To evaluate the impact of three treatment modalities, superficial truncal vein ablation, perforator vein ablation, and deep venous stenting on venous leg ulcer (VLU) healing, as well as their cumulative effect on ulcer healing, in an attempt to establish the best algorithm for the treatment of chronic and recalcitrant VLUs. METHODS: Multicenter retrospective cohort study using a standardized database to evaluate patients with chronic venous ulcers treated between January 2013 and December 2017. RESULTS: Eight-hundred thirty-two consecutive patients with VLU were identified at 11 centers in the United States. All patients were initially managed with wound care and compression for at least 2 months. Compression and wound care management alone, used in 187 patients, led to ulcer healing in 75% of patients by 36 months. Ulcer recurrence in patients managed without surgery at 6, 12, and 24 months was 3%, 5% and 15%, respectively. Five hundred twenty-eight patients underwent ablation of incompetent superficial veins, and 344 of those also underwent incompetent perforator ablation. Patients who underwent truncal vein ablation alone had an ulcer healing rate of 51% at 36 months. Patients who received both superficial and perforator ablation were significantly younger, and had a 17% improvement in healing at 36 months (68% vs 51%, respectively), but there was no impact of combined superficial and perforator ablations on ulcer recurrence rates. One hundred thirty-four patients had stenosis of one of more lower extremity deep veins and 95 (71%) underwent endovenous stenting. Ulcer healing and recurrence rates for those who underwent stent placement alone was 77% and 27%, respectively, at 36 months. Patients who underwent deep venous stenting and ablation of both incompetent truncal and perforator veins had an ulcer healing rate of 87% at 36 months and ulcer recurrence of 26% at 24 months. CONCLUSIONS: This study demonstrates that correction of superficial truncal vein reflux, as well as deep vein stenosis, both contribute to healing of VLU. Patients who fail to heal their VLU after superficial and perforator ablation should have the iliocaval system imaged to identify hemodynamically significant stenoses or occlusions amenable to stenting, which facilitates venous ulcer healing even in patients with large ulcers.

Celiac artery stent placement for coronary ischemia.

INTRODUCTION: The use of endovascular technology for mesenteric interventions has become an increasingly accepted treatment modality. We present an unusual case of celiac artery stent placement for coronary ischemia. CASE DESCRIPTION: A 66-year-old male with a history most notable for coronary artery disease and coronary artery bypass grafting (CABG) x 3 utilizing left internal mammary artery to left anterior descending, radial artery to first diagonal and his right gastroepiploic artery (GEA) to posterior descending artery presented with chest pain. His work-up included a cardiac catheterization that revealed a 90% stenosis at the origin of the celiac axis. A subsequent computerized tomography angiogram confirmed this and noted moderate stenosis of his superior mesenteric artery (SMA) as well as severe inferior mesenteric artery (IMA) stenosis. The patient was taken for mesenteric angiography by vascular surgery at which time he underwent balloon-expandable stent placement in the celiac axis. The patient tolerated this procedure well and was noted to have an improvement in his symptoms postoperatively. DISCUSSION: Use of arterial conduits for CABG have proven to be superior to vein. Long-term viability of the GEA as a conduit is dependent in part on the patency of mesenteric circulation. Our findings demonstrate a viable endovascular treatment option for angina pectoris secondary to mesenteric stenosis in this unique patient population.

Cura de ORR en pie diabético / Cure for ORR in the diabetic foot

El principio dominante del método de Orr es favorecer con la inmovilización rigurosa la defensa tisular contra la infección. Durante la Guerra Civil Española era utilizado en fracturas abiertas, se realizaba limpieza quirúrgica, se aplicaba vaselina sobre la herida y se cubría con bota de yeso por 2 o 3 semanas, a menos que el paciente presentara fiebre. Evaluar la efectividad del uso de la "cura de Orr" en pie diabético en el Hospital Universitario de Coro "Dr. Alfredo Van Grieken", durante el período octubre 2008-marzo 2009. Estudio prospectivo, descriptivo en un lapso de 6 meses, incluyendo pacientes con pie diabético grado III y IV según la clasificación de Wagner modificada. Se evalúa número de curas de Orr necesarias para la cicatrización de la úlcera, intervalo de tiempo del cambio de la cura, período de cicatrización de las lesiones y complicaciones presentadas con este método de cura. A un total de siete pacientes durante el período octubre 2008-marzo 2009, se les realizó entre 4 y 7 curas para lograr cicatrización, la cual se obtuvo antes de los 06 meses en 100 por ciento de los pacientes, realizándose el cambio de cura en intervalos de tiempo variables, presentando un paciente atopia dermatológica al material utilizado. La técnica de Orr es una buena opción para el manejo de úlcera por pie diabético, con resultados sarisfactorios, obteniéndose un pie funcional.

Pathology-dependent histological changes of the left stellate Ganglia: a cadaveric study.

Sympathetic hyperinnervation due to nerve sprouting generated by the left stellate ganglion has been noted following cardiopulmonary disease processes. Sympathetic hyperinnervation seems to be limited to cardiopulmonary diseases in the experimental and clinical settings. However, histological changes of the left stellate ganglion following cardiopulmonary diseases in humans have vet to be observed. This study intends to investigate the histological changes of cadaveric sympathetic nervous tissue of left stellate ganglia (n = 32) and their relationship to noted pathology. Our study found fibrotic changes of the left stellate ganglion are not significantly dependent upon pathological processes, however, changes in the number of nerve cell bodies seems to be pathology dependent. A relationship between respiratory (mean = 33.3; P = 0.023) and cardiovascular pathologies (mean = 29.6; P = 0.199) and an increase in nerve cell bodies of the left stellate ganglion was noted when compared to other pathologies (mean = 25.7). The link between cardiopulmonary disease and sympathetic hyperinnervation may be the increase in the number of nerve cell bodies of the left stellate ganglion. Our results are clinically significant considering sympathetic hyperinnervation is associated with arrythmogenesis and an increase in morbidity and mortality in patients with pulmonary disease. Such findings may warrant investigation into the use of ganglion blockade in cardiopulmonary diseases.