[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]. / Curriculum Klinische Akut- und Notfallmedizin ­ Schwerpunkt Innere Medizin : Empfehlung zu Weiterbildungsinhalten der Inneren Medizin in der Notaufnahme.

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

A Very Rare Cause of Thrombotic Peripheral Occlusion.

A 45-year-old healthy woman presented with claudication of the right leg. The resting ankle-brachial index (ABI) was reduced to 0.6, and a duplex scan revealed an occlusion of the right popliteal artery. Angiography presented a patent superficial femoral artery that ends above the knee joint. Laterally, there was delayed retrograde contrast filling of the popliteal artery. After exploring the internal iliac artery, we crossed a thrombotic occlusion of a persisting sciatic artery (PSA). Local thrombolysis with recombinant tissue plasminogen activator (1 mg/h) was initiated. The Angiography 18 hours later showed a reduction of thrombotic material and relevant stenosis in the proximal part of the vessel. Residual thrombus and the stenosis were covered by two stentgrafts (Gore Viabahn Endoprosthesis) that were stabilized by an interwoven stent (Supera). Final angiography displayed a patent sciatic artery and a three-vessel run off. Postinterventional ABI was normalized to 1.0. The magnetic resonance imaging 6 days after the intervention demonstrated a patent PSA again and a normal blood flow on the left leg. A PSA should be included in the differential diagnosis of lower limb ischemia or suspected aneurysm formation. We demonstrated the feasibility of an interventional approach with an excellent outcome in this case.

Lutonix® 014 DCB global Below the Knee Registry Study: interim 6-month outcomes.

BACKGROUND: The most common clinical presentation of peripheral artery disease (PAD) comprises intermittent claudication (IC), but about one third of patients will progress to critical limb ischemia (CLI), characterized by rest pain and/or tissue loss, which is the most severe limb manifestation of PAD. Paclitaxel-coated balloons are well established for the endovascular treatment of femoropopliteal lesions in patients with IC and CLI. This ongoing multicenter registry study is exploring the role of the Lutonix® 014 drug-coated balloon (DCB) in the treatment of below-the-knee (BTK) arteries and CLI. METHODS: Three hundred fourteen (314) patients were enrolled from 26 sites and 12 countries. The real-world patients represent those undergoing intervention for BTK arteries with the Lutonix® 014 DCB. The study had both, primary safety and primary efficacy endpoints. The primary safety endpoint was freedom at 30 days from BTK major adverse limb event (MALE) + perioperative death (POD). Primary efficacy was freedom from clinically driven target lesion reintervention (fTLR) at 6 months. Additional secondary endpoints related to safety were reported. RESULTS: The interim 6 months' results showed freedom from MALE and POD at 30 days of 98.6% and at 6 months (180 days) of 96.0%. Primary efficacy of fTLR at 6 months (180 days) was 87.9%. Safety related secondary endpoints at 6 months (180 days) showed freedom from all of the following: all cause death of 91.2%, above ankle amputation 97.1%, reintervention for thrombosis 95.2%, reintervention for distal embolization 100.0%, and target vessel revascularization of 88.0%. There were no unexpected device or drug related events reported. CONCLUSIONS: The interim 6-month outcomes demonstrate the safety and efficacy of the Lutonix® 014 DCB for the treatment of BTK arteries.

Retrograde approach for complex popliteal and tibioperoneal occlusions.

PURPOSE: To describe the technical aspects of the retrograde approach for endovascular treatment of complex popliteal and/or tibioperoneal occlusions and determine its efficacy in minimizing failure rates. METHODS: An observational registry of retrograde revascularizations was maintained at our institution over 14 months (September 2006 to December 2007). During this time frame, antegrade revascularization failed in 62 (17.8%) of 343 limbs with complex total occlusions of the popliteal and/or infrapopliteal vascular territory. Of these antegrade failures, 51 (82.2%) limbs in 51 patients (32 men; mean age 72+/-8 years) were suitable for a retrograde attempt. From this subgroup, 45 (88.2%) were treated via a percutaneous transpedal access site and 6 (11.8%) via a transcollateral intra-arterial technique. RESULTS: The overall success rate was 86.3% (44/51); adjunctive stenting was needed in 21 (41.1%) to optimize results. Only 1 (1.9%) major complication (a pedal access site occlusion) and 4 (7.8%) minor sequelae (arterial perforation in 3 and a pedal hematoma without consequence) were documented. CONCLUSION: In complex popliteal to infrapopliteal occlusions, an antegrade recanalization attempt can fail in up to 20% of the cases. The additional use of a retrograde approach seems feasible and safe and can favorably modify this failure rate. This technique could be valuable for patients with critical limb ischemia due to popliteal and infrapopliteal occlusions once larger studies with follow-up confirm safety, efficacy, and clinical benefit.