Lower-extremity arterial revascularization: Is there any evidence for diabetic foot ulcer-healing?

The presence of peripheral arterial disease (PAD) is an important consideration in the management of diabetic foot ulcers. Indeed, arteriopathy is a major factor in delayed healing and the increased risk of amputation. Revascularization is commonly performed in patients with critical limb ischaemia (CLI) and diabetic foot ulcer (DFU), but also in patients with less severe arteriopathy. The ulcer-healing rate obtained after revascularization ranges from 46% to 91% at 1 year and appears to be improved compared to patients without revascularization. However, in those studies, healing was often a secondary criterion, and there was no description of the initial wound or its management. Furthermore, specific alterations associated with diabetes, such as microcirculation disorders, abnormal angiogenesis and glycation of proteins, can alter healing and the benefits of revascularization. In this review, critical assessment of data from the literature was performed on the relationship between PAD, revascularization and healing of DFUs. Also, the impact of diabetes on the effectiveness of revascularization was analyzed and potential new therapeutic targets described.

Eumycetoma of the foot caused by Exophiala jeanselmei in a Guinean woman.

Eumycetomas are chronic infectious entities characterized by presence of mycotic grains in (sub-)cutaneous tissues, after accidental inoculation of an exogenous filamentous fungus in the skin. The lesions evolve towards painless pseudotumor of the soft parts. We report the original case of a Guinean woman exhibiting eumycetoma of the right foot. Both laboratory tests identified a dematiaceous fungus, Exophiala jeanselmei, as the responsible infectious agent. A medical treatment with voriconazole alone was sufficient to notice a substantial clinical improvement. This finding is unusual as E. jeanselmei is uncommon in Guinea-Conakry, and as optimal treatment rather associate antifungal azoles and surgical excision.

Monitoring plaque inflammation in atherosclerotic rabbits with an iron oxide (P904) and (18)F-FDG using a combined PET/MR scanner.

PURPOSE: The aim of this study was to compare the ability of (18)F-FDG PET and iron contrast-enhanced MRI with a novel USPIO (P904) to assess change in plaque inflammation induced by atorvastatin and dietary change in a rabbit model of atherosclerosis using a combined PET/MR scanner. MATERIALS AND METHODS: Atherosclerotic rabbits underwent USPIO-enhanced MRI and (18)F-FDG PET in PET/MR hybrid system at baseline and were then randomly divided into a progression group (high cholesterol diet) and a regression group (chow diet and atorvastatin). Each group was scanned again 6 months after baseline imaging. R2* (i.e. 1/T2*) values were calculated pre/post P904 injection. (18)F-FDG PET data were analyzed by averaging the mean Standard Uptake Value (SUVmean) over the abdominal aorta. The in vivo imaging was then correlated with matched histological sections stained for macrophages. RESULTS: (18)F-FDG PET showed strong FDG uptake in the abdominal aorta and P904 injection revealed an increase in R2* values in the aortic wall at baseline. At 6 months, SUVmean values measured in the regression group showed a significant decrease from baseline (p = 0.015). In comparison, progression group values remained constant (p = 0.681). R2* values showed a similar decreasing trend in the regression group suggesting less USPIO uptake in the aortic wall. Correlations between SUVmean or Change in R2* value and macrophages density (RAM-11 staining) were good (R(2) = 0.778 and 0.707 respectively). CONCLUSION: This experimental study confirms the possibility to combine two functional imaging modalities to assess changes in the inflammation of atherosclerotic plaques. (18)F-FDG-PET seems to be more sensitive than USPIO P904 to detect early changes in plaque inflammation.

Midterm outcomes of embolisation of internal iliac artery aneurysms.

OBJECTIVES: There is no standardised technique for internal iliac artery aneurysm (IIAA) embolisation and results of long-term prevention of rupture are unknown. DESIGN: We retrospectively evaluated technical aspects and results of IIAA embolisation in a multicentre study. METHODS: Aneurysm morphology and embolisation techniques were reviewed. Aneurysm-related death, rupture, diameter increase, endoleak, secondary procedure and complication related to the IIA occlusion were recorded. RESULTS: Between 2001 and 2011, 53 patients with 57 IIAA were treated. Mean diameter of IIAA was 41 mm (range: 25-88 mm). Embolisation techniques were distal and proximal occlusion (n = 24), proximal occlusion (n = 18) and sac packing (n = 15). Cumulative overall survival rate was 92% at 1 year, 83% at 3 years and 59% at 5 years. No cause of deaths was related to aneurysm. Aneurysm diameter increased in five patients and endoleak was observed in 11 patients. One secondary open conversion and five secondary endovascular procedures were performed for increase of diameter or proximal endoleak. Two patients experienced a disabling buttock claudication. CONCLUSIONS: Embolisation of IIAA is safe in the short- and midterm. However, endoleak and aneurysm diameter increases are not rare. Yearly post-procedure computed tomography angiography seems appropriate.

Conversion to open repair after endovascular aneurysm repair: causes and results. A French multicentric study.

OBJECTIVE: To evaluate the causes and results of conversion to open repair after aortic aneurysm endovascular treatment (EVAR). DESIGN: Retrospective study of open conversion after EVAR was performed in eight French academic centres. Primary conversion (PC) within 30 days after EVAR and secondary conversions (SC) were analysed separately. RESULT: Between 1997 and 2007, open conversions were performed in 34 patients (most often in high-risk patients): 14 PC and 20 SC. Two main causes of PC were unfavourable iliac artery anatomy and renal artery coverage. In hospital mortality was 21%. SC occurred at a median of 44 months after primary EVAR. Nine were urgent cases for rupture or infection and 11 elective for aneurysm growth, infection or thrombosis. Early mortality was similar after emergent or elective SC (25%). CONCLUSION: Open conversion, and, in particular, PC and urgent SC, was associated with a poor outcome. According to the literature, mortality after elective SC is low but remains high in high-risk patients.

Evaluation of a new vascular suture system for aortic laparoscopic surgery: an experimental study on pigs and cadavers.

OBJECTIVES: The aim of this study was to assess the feasibility and efficacy of a new laparoscopic vascular suturing device. METHODS: Animal study: six pigs underwent surgery using a retroperitoneal laparoscopic approach. Aorto-prosthetic side-to-end and end-to-end anastomoses were performed laparoscopically on each pig using SuDyn. Clamping and anastomosis times, as well as the properties of the anastomoses, were recorded. Study on cadavers: four aorto-prosthetic end-to-end anastomoses were performed using the direct transperitoneal laparoscopic approach to assess the feasibility of the SuDyn device on atherosclerotic aortas. RESULTS: Animal study: No pigs died and 12 patent and impermeable anastomoses were obtained. Mean anastomosis time was 38(+/-8)min for end-to-side anastomoses and 37(+/-5)min for end-to-end anastomoses. Study on cadavers: Totally laparoscopic anastomoses were performed in 4 human cadavers with a mean anastomosis time of 37(+/-3)min. CONCLUSIONS: SuDyn makes laparoscopic aorto-prosthetic anastomoses easier to perform, produces good results and does not require a learning curve.

[Exercise-induced dyspnea and hilar enlargement]. / Dyspnée d'effort et gros hiles.

We report the case of a 46-year-old man with an uneventful history who was hospitalized for suspected pulmonary embolism. The chest x-ray did not reveal any parenchymatous anomaly but disclosed pseudo-tumoral enlargement of the pulmonary arteries. There was no right ventricular overload at cardiac echography and the pulmonary arterial pressure was normal. Helicoidal angioscan demonstrated aneurismal dilatation of the both pulmonary arteries, complicated by a thrombus on the right. Outcome was favorable with anticoagulation. After ruling out acquired aneurysm, the diagnosis retained was idiopathic aneurysm of the pulmonary arteries.

[Transient intestinal pseudo-obstruction syndrome in premature infants]. / Le syndrome de pseudo-obstruction intestinale transitoire du prématuré.

BACKGROUND: A chronic intestinal pseudo-obstruction is sometimes seen in premature neonates who are fed early and subsequently suffer from digestive intolerance for several weeks. PATIENTS: Seven premature babies (mean gestational age: 30.5 weeks, mean birthweight: 950 g) suffered from abdominal distension and failure to pass stools at a mean age of 2.5 days (extremes: 1 to 6 days); 2 of them also had vomiting. X-ray examination showed dilated loops of bowel throughout the abdomen without obstructive changes; barium or Gastrografin studies demonstrated inertia of the colon without obstructive changes or abrupt changes in caliber. Histological examination of enteric nerve cells in 2 cases showed normal maturation. Parenteral nutrition was necessary in all patients for 30 to 78 days (mean: 47), followed by continuous enteral feeding for 24 to 48 days (mean: 37). Septicemia complicated parenteral nutrition in 4 babies and was responsible for the death of 1 of them. Normal evacuation of stools occurred between day 27 and day 91 (mean day 46) allowing normal enteral feeding. All 6 patients, now aged 2.5 to 8 years (mean 3.5 years) are in good health, and have no digestive problems. CONCLUSIONS: Immaturity of intestinal motility may occur in some premature neonates suffering from intestinal ileus. Parenteral nutrition may be necessary for several weeks, but spontaneous recovery is usual. This transient intestinal pseudo-obstruction of premature babies is different from the classical chronic pseudo-obstruction for which surgery is often needed.