Enhancing limb salvage by non-mobilized peripheral blood angiogenic cell precursors therapy in patients with critical limb ischemia.

BACKGROUND: Stem cell therapy has been proposed to enhance the salvage of critically ischemic limbs. OBJECTIVE: Assess the efficacy and safety of the implantation of non-mobilized peripheral blood angiogenic cell precursors (NMPB-ACPs) in patients with critical limb ischemia (CLI) who were poor candidates for standard revascularization treatment options. MATERIAL AND METHOD: Six patients with CLI due to the infrapopliteal artery occlusive disease were included in the present study. Intramuscular injections of NMPB-ACPs were administered in the ischemic limbs. The efficacy was evaluated by clinical outcomes, ankle brachial index, toe brachial index, and computerized tomographic angiography. RESULTS: There was no evidence of local or systemic complication related to the procedure. Five patients (83.3%) had clinically significant improvement of adequate circulation at the distal limb for the complete healing. Four of them had complete healing of ischemic ulcers and stumps of toe amputation. However one patient with adequate granulation tissue at the stump of the left first toe amputation subsequently suffered from severe foot infection originating from the other toes and eventually underwent below knee amputation. There was no improvement of circulation at the distal limb after the administration of NMPB-ACPs in one patient (16.7%) who eventually underwent major amputation. CONCLUSION: The preliminary result of NMPB-ACPs therapy may be safe and provide benefits in the improvement of circulation in patients with CLI. A larger controlled trial is required to ascertain these preliminary results.

Acute arterial embolism of the lower extremities: impact of 24-hour duration on the outcome of management.

OBJECTIVE: Determine the impact of 24-hour duration of arterial embolism on the outcomes of management. MATERIAL AND METHOD: A prospective study of 91 patients with acute arterial embolism of the lower extremities was carried out. RESULTS: Among the 91 patients, 31(34.1%) were with early acute embolism(< 24 hours) and 60 (65.9%) were with late acute embolism (> 24 hours). Extensive limb gangrene was more common in patients with late acute embolism (26.7% versus 3.2%, p = 0.009). Subsequently, primary major amputation was higher in those patients (20% versus 3.2%, p = 0.05). In early acute embolism, surgical embolectomy was only the primary treatment of revascularization (87.1%) whereas in late acute embolism, there were varying modalities of revascularization (68.3%) in addition to surgical embolectomy. The successful revascularization after the initial surgical embolectomy was significantly higher in patients with early acute embolism (92.6% versus 43.9%, p < 0.001). Patients with late acute embolism had a higher tendency of undergoing major amputation after revascularization (24.4% versus 7.4%, p = 0.106). Successful outcome was higher in patients with early acute embolism (83.9% versus 58.3%, p = 0.014). CONCLUSION: The 24- hour duration of arterial embolism may be a crucial factor influencing the outcome in the management of this disease.

Successful management of asymptomatic penetrating carotid artery injury.

A 30-year-old male sustained a gunshot wound (GSW) in zone II of the left side of his neck. Initially, an inlet wound had an active bleeding which stopped later. When he arrived at our hospital, his vital signs had stabilized and the examination showed no abnormality in the aerodigestive tract and normal focal signs of hemispheric function. There was only a positive sign in paresthesia at the lateral aspect of his left shoulder and upper arm. He had undergone several investigations and then, was treated successfully by repairing his left carotid artery with a reversed saphenous vein graft. To our knowledge, this is a rare case of asymptomatic penetrating carotid artery injury. In this paper, we also reviewed literatures discussing about investigations and controversial issues in the management of a zone II penetrating neck injury.

Endovascular abdominal aortic aneurysm repair in high risk patients: outcomes of management.

BACKGROUND: The concomitant cardiopulmonary disease precluded the elective repair for abdominal aortic aneurysm (AAA) with acceptable risk. The endovascular abdominal aortic aneurysm repair (EVAR) has become an alternative method for the treatment of AAA with high-risk comorbidities. OBJECTIVE: Evaluate the results of EVAR in high-risk patients with large AAA. MATERIAL AND METHOD: A prospective study of high-risk patients with large AAA and suitable morphology who underwent EVAR between August 2003 and August 2005 was conducted. The long-term outcomes were observed up to December 2006. The comorbidities, size of aneurysm, types of procedures, operative time, amount of blood loss and transfusion, length of postoperative stay in intensive care unit and hospital, postoperative complications and mortality were analyzed. RESULTS: Eight patients (7 males and 1 female) with the mean age of 71.4 years (range 66-83 years) were included in the present study. The comorbidities were six of compromised cardiac status, one of severe pulmonary disease and one of morbid obesity. The average size of aneurysm was 6.2 +/- 0.64 centimetres. One patient also had large bilateral iliac artery aneurysms. Seven patients underwent EVAR with bifurcated aortic stent graft and one proceeded with aorto uni-iliac stent graft. Three patients underwent preoperative coil embolisation into internal iliac arteries when the distal landing zones at the external iliac arteries were considered. The mean estimated blood loss was 369cc and the mean blood transfusion was 0.88 units. There were no perioperative mortality, early graft occlusion, AAA rupture and open conversion in the present study. One patient had cardiac arrest due to upper airway obstruction but with successful treatment. Type II endoleak was observed in one patient and successfully treated by expectant management. One limb of bifurcated stent graft was occluded at the 5th month post EVAR and was successfully treated by artery bypass surgery at both groins. The 3-year primary graft limb patency was 87.5% (7/8). The survivals of patients at 1, 2 and 3 years were 100%, 100% and 87.5% respectively. The cause of death in one patient was not related to EVAR. CONCLUSION: EVAR may be a safe and effective alternative to open AAA repair especially in high-risk patients.

Treatment of iatrogenic pseudoaneurysm of brachial artery with percutaneous ultrasonographically guided thrombin injection (PUGTI): a case report and a literature review.

OBJECTIVE: Report the successful treatment of iatrogenic pseudoaneurysm of the brachial artery with the percutaneous ultrasonographically guided thrombin injection (PUGTI). MATERIAL AND METHOD: The pseudoaneurysm was caused by an accidental puncture into a native brachial artery instead of the venous side of an arteriovenous fistula during hemodialysis. The aneurysmal sac had a large size with a short neck, vulnerable to intra-arterial thrombosis and distal artery embolization during the thrombin glue injection. RESULTS: This procedure was secured by using color duplex ultrasonography (CDU) for the accurate positioning of the needle and the assessment of the optimal dosage of the injected bovine thrombin. After the procedure, an elastic compression was applied at the injection site to prevent the reentry of blood flow into the aneurysmal sac. The flow in the aneurysmal sac completely disappeared in seven days after the treatment. The 4-month follow-up demonstrated the complete resolution of the aneurysmal sac. CONCLUSION: Percutaneous injection of bovine thrombin under ultrasound guidance is possible as one of the minimal invasive procedures to treat the pseudoaneurysm of the extremity artery.

Atherosclerosis obliterans of the lower extremities in Thai patients.

BACKGROUND: Major limbs loss and high mortality rate were observed in the management of Thai patients with atherosclerosis obliterans (ASO) of the lower extremities. These were the results of delayed diagnosis and treatment together with the associated morbidities. There is a lack of information of this disease resulting in a lack of knowledge and awareness of this problem among general practitioners in Thailand. OBJECTIVES: The purposes of this study were (1) to identify the prevalence of this disease in a tertiary care hospital, (2) to enumerate the risk factors and comorbidities, (3) to identify clinical characteristics of the disease and (4) to evaluate the outcomes of treatment. MATERIAL AND METHOD: A prospective study ofpatients with ASO of the lower extremities was carried out between January 2000 and December 2004. Patients having clinical manifestations of chronic and acute arterial occlusion with the absence of ankle pulse were included in the present study. Evidence of atheromatous plaque by angiography, operative finding, and histopathology of arterial wall from amputated specimens were used to confirm the diagnosis. The selection of surgical treatments for this disease such as revascularization, major amputation, minor amputation and debridement depended on the severity of limb ischaemia, the status of distal artery and the patients' general condition. The risk factors, comorbidities, clinical manifestations, site of arterial occlusion, severity of ischaemia, types of surgical treatment and outcomes of management were analyzed. RESULTS: Four hundred and fourteen consecutive patients with ASO were diagnosed in the present study with a prevalence of 1.02:1,000. Femoro-popliteal arterial segment was the most common site (221 cases, 53.4%) of the affected arteries. Diabetes mellitus (253 cases, 61. 1%) was the most common risk factor of ASO followed by hypertension (217 cases, 52.4%), smoking (195 cases, 47.1%) and hyperlipidemia (172 cases, 41.5%). Ischaemic heart disease (108 cases, 26.1%) was the most common comorbidity of ASO followed by major stroke (56 cases, 13.5%) and chronic renal failure (20 cases, 4.8%). Patients with ASO presented mostly as chronic manifestations (385 cases, 93%) or with limb-threatening condition (326 cases, 78.7%). The clinical manifestations were ischaemic ulcer and/or digital gangrene (251cases, 60.6%), rest pain (182 cases, 44.0%) incapacitating claudication (62 cases, 15.0%) and acute ischaemic pain (29 cases, 7.0%). One hundred and thirty eight (33.3%) patients had significant lower limb infection at the time of admission. One hundred and seventy one (41.3%) patients underwent revascularization procedures as the major primary treatments to salvage the limbs. The success rate of limb salvage after revascularization was 76.6% (13 1/171). Major amputation after revascularization was 16. 9%(29/ 171). Perioperative mortality rate of revascularization procedure was 8.2 %(14/171). Major amputation was required as the primary treatment due to infective (18.4%, 76/414) and ischaemic process (6.5%, 27/414). The mortality rate of primary major amputation for infection and ischaemia were 19.7%(15/76) and 25.9%(7/2 7) respectively. The total mortality rate in the present study was 11.3% (47/414). The common causes of death were sepsis and ischaemic heart disease. CONCLUSION: ASO of the lower extremities is one of the major problems for national health care causing major limb loss and death. Arterial bypass surgery was the most effective treatment for limb salvage. Management of this disease at the terminal stage causes high morbidity and mortality. Hence, early detection of this disease and correction of the risk factors should be the most effective strategy to improve the overall outcome of the management of this complicated problem.

A 20-year-old female with impending foot gangrene: How to interpret her laboratory results.

A 20-year-old female presented with multi-system involvement. At first, she had acute cholecystis and was treated by cholecystectomy. After the operation she had neurological symptoms and was diagnosed with herpes encephalitis, confirmed by CSF serology. One month later she developed left foot arterial occlusion. Autoimmune hemolytic anemia with immune thrombocytopenia (Evan’s syndrome) and myocarditis were also detected concurrently. Her primary disease was suspected to be systemic lupus erythematosus. However, her antinuclear antibody assayed by the enzyme-link immunoassay (ELISA) method was negative twice but became positive by indirect immunofluorescence method. Other positive laboratory results were lupus anticoagulant, antineutroplil cytoplasmic antibody (ANCA), and anti proteinase 3 (anti-PR3). Their relevance will be discussed in details. She was given steroids, anticoagulants and underwent a femerofemoral bypass. Her clinical status improved afterwards.

Deadly soft tissue sarcoma: Curable using a multidisciplinary approach.

We present the role of multidisciplinary approach to treat our patient with a soft tissue sarcoma at her thigh successfully. A 56-year-old female complained of a progressive enlarging soft tissue mass on her thigh before the diagnosis of malignant fibrous histiocytoma was confirmed by appropriate approach. With final diagnosis and staging of the disease, the appropriate treatment was decided from all members of Siriraj Musculoskeletal Tumor Board to save not only patient's life but also preserve her extremity and function.

A young woman with inevitable limb loss.

We report a pitfall in the management of a young 43-year-old female who presented with a history of claudication and threaten limb loss. Inappropriate axillobifemoral bypass graft surgery was performed, resulting in perioperative graft failure with progressive inevitable gangrene of the left leg. Rescue surgery was performed to salvage the right limb but she developed perioperative myocardial infarction. Delayed amputation was justified, pre-operative cardiac evaluation and aggressive percutaneous coronary intervention was performed followed by an uneventful definitive below-knee amputation of left leg. The patient was discharged and was referred for a left leg prosthesis.