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Segmental arterial mediolysis is a noninflammatory nonatherosclerotic vasculopathy of uncertain etiology characterized by dissection and/or aneurysm formation. It affects medium-to-large arteries, primarily the celiac, superior mesenteric, and renal arteries. Iliac involvement is rare, and its specific treatment has not been described. We detail a patient who presented with intrabdominal hemorrhage from a ruptured right colic artery aneurysm. He underwent transcatheter arterial embolization followed by right hemicolectomy. Histopathology confirmed the diagnosis of segmental arterial mediolysis. Endovascular treatment of a 3-cm iliac artery aneurysm was performed 18 months later. There was successful exclusion of the aneurysm demonstrated on computed tomography angiography at 10 years.
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BACKGROUND: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system has been validated to predict wound healing among patients with critical limb threatening ischemia (CLTI). Our goal was to analyze the use of a previously reported conservative wound care approach to non-infected (foot infection score of zero), diabetic foot ulcers with mild-moderate peripheral arterial disease enrolled in a conservative tier of a multidisciplinary limb preservation program. METHODS: Veterans with CLTI and tissue loss were prospectively enrolled into our Prevention of Amputation in Veterans Everywhere (PAVE) program. All patients with wounds were stratified to a conservative approach based on perfusion evaluation and a validated pathway of care. Retrospective analysis of a prospectively maintained database was performed to evaluate all conservatively managed patients presenting without foot infection for the primary outcome of wound healing as well as secondary outcomes of time to wound healing, delayed revascularization, wound recurrence, and limb loss. RESULTS: Between January 2006 and December 2019, 1113 patients were prospectively enrolled into the PAVE program. A total of 241 limbs with 281 wounds (217 patients) were stratified to the conservative approach. Of these, 122 limbs (89 patients) met criteria of having diabetic foot wounds without infection at the time of enrollment and are analyzed in this report. Of the 122 limbs, 97 (79.5%) healed their index wound with a mean time to healing of 4.6 months (0.5-20 months). Wound recurrence ensued in 44 (45.4%) limbs, 93.2% of which healed again after recurrence. There were three (3.1%) limbs requiring major amputation in this group (one due to uncontrolled infection and two due to ischemic tissue loss). Of the 25 (20.5%) limbs that did not heal initially, four (16%) required amputation due to progressive symptoms of CLTI. CONCLUSIONS: In patients with diabetes and lower extremity wounds without infection in the setting of mild to moderate peripheral arterial disease, there appears to be an acceptable rate of index wound healing, and appropriate rate of recurrent wound healing with a low risk of limb loss. While wound recurrence is frequent, this can be successfully treated without the need for revascularization.
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Diabetes Mellitus , Pie Diabético , Enfermedad Arterial Periférica , Amputación Quirúrgica , Tratamiento Conservador/efectos adversos , Pie Diabético/cirugía , Pie Diabético/terapia , Humanos , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Recuperación del Miembro , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/terapia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
INTRODUCTION: Major lower extremity amputation (LEA) results in significant morbidity and mortality. This study identifies factors contributing to adverse long-term outcomes after major LEA. STUDY DESIGN: Amputations in the Vascular Quality Initiative (VQI) long-term follow-up database from 2012 to 2017 were included. Multivariable logistic regression determined which significant patient factors were associated with 1-year mortality, long-term functional status, and progression to higher level amputation within 1 year. RESULTS: 3440 major LEAs were performed and a mortality rate of 19.9% was seen at 1 year. Logistic regression demonstrated that 1-year mortality was associated with post-op myocardial infarction (MI) (odds ratio (OR) 1.7, CI 1.02-2.97, P = .04), congestive heart failure (CHF) (OR 1.9, confidence interval (CI) 1.56-2.38, P < .001), hypertension (HTN) (OR 1.31, CI 1.00-1.72, P = .05), chronic obstructive pulmonary disease (COPD) (OR 1.36, CI 1.13-1.63, P < .001), and dependent functional status (OR 2.01, CI 1.67-2.41, P < .001). A decline in ambulatory status was associated with COPD (OR 1.36, CI 1.09-1.68, P = .006). Dependent functional status was protective against revision to higher level amputation (OR .18, CI .07-.45, P < .001). CONCLUSION: In the VQI, 1-year mortality after major LEA is nearly 20% and associated with HTN, CHF, COPD, dependent functional status, and post-op MI. Decreased functional status at 1 year was associated with COPD, and progression to higher level amputation was less likely in patients with dependent functional status.
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Amputación Quirúrgica/estadística & datos numéricos , Extremidad Inferior/cirugía , Complicaciones Posoperatorias/epidemiología , Anciano , Amputación Quirúrgica/mortalidad , Femenino , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/mortalidad , Humanos , Hipertensión/complicaciones , Hipertensión/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Sistema de Registros , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Patient frailty indices are increasingly being utilized to anticipate post-operative complications. This study explores whether a 5-factor modified frailty index (mFI-5) is associated with outcomes following below-knee amputation (BKA). All BKAs in the vascular quality initiative (VQI) amputation registry from 2012-2017 were reviewed. Preoperative frailty status was determined with the mFI-5 which assigns one point each for history of diabetes, chronic obstructive pulmonary disease or active pneumonia, congestive heart failure, hypertension, and nonindependent functional status. Outcomes included 30-day mortality, unplanned return to odds ratio (OR), post-op myocardial infarction (MI), post-op SSI, all-cause complication, revision to higher level amputation, disposition status, and prosthetic use. 2040 BKAs were performed. Logistic regression showed an increasing mFI-5 score that was associated with higher risk of combined complications (OR 1.22, confidence interval [CI] 1.07-1.38, P < .05), 30-day mortality (OR 1.60, CI 1.19-2.16, P < .05), post-op MI (OR 1.79, CI 1.30-2.45, P < .05), and failure of long-term prosthetic use (OR 1.17, CI 1.03-1.32, P < .05). In the VQI, every one-point increase in mFI-5 is associated with an increased risk of 22% for combined complications, 60% for 30-day mortality, nearly 80% for post-op MI, and 17% for failure of prosthetic use in BKA patients. The mFI-5 frailty index should be incorporated into preoperative planning and risk stratification.
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Amputación Quirúrgica , Fragilidad/clasificación , Extremidad Inferior/cirugía , Enfermedad Arterial Periférica/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Comorbilidad , Evaluación de la Discapacidad , Femenino , Humanos , Extremidad Inferior/irrigación sanguínea , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Readmisión del Paciente , Complicaciones Posoperatorias/mortalidad , Valor Predictivo de las Pruebas , Sistema de Registros , Reoperación , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/mortalidadRESUMEN
BACKGROUND: Guidelines recommend that patients with carotid artery stenosis ≥50% (Sx-CAS) undergo carotid endarterectomy (CEA) within 14 days of symptoms. However, perioperative risks, especially stroke, may be increased when CEA is performed within 48 hours. This study seeks to more fully evaluate the effect of timing of surgery on outcomes for Sx-CAS. METHODS: All CEAs in the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) from 2012 to 18 were reviewed. Ipsilateral cortical or visual symptoms within 6 months defined Sx-CAS. Timing from symptom occurrence to CEA was classified as immediate (0-2 days), early (3-14 days), or delayed (>14 days). Perioperative stroke, myocardial infarction (MI), and 30-day mortality rates were compared by time to surgery. RESULTS: Of 2203 CEAs, 436 (20%) were for Sx-CAS (52% stroke, 48% transient ischemic attack). Mean time from symptoms to CEA was 28.3 days (range, 0-172; median, 14 days). Sixty-one cases (14%) were immediate, 166 (38%) early, and 209 (48%) delayed. Perioperative stroke occurred in 2.8% and stroke/MI/30-day mortality in 5.7%. Stroke rate was significantly higher in the immediate group (vs. early and delayed): 8.2%, versus 3.0%, and 0.96%, respectively (P = 0.009). Stroke/MI/30-day mortality was also higher in the immediate group: 13.1%, versus 6.0%, and 3.3%, respectively (P = 0.001). Immediate surgery was associated with greater postoperative events (P = 0.009), and logistic regression confirmed decreased risk of postoperative stroke and stroke/MI/30-day mortality in delayed surgery using immediate surgery as a reference. Wide variability existed among centers in the timing of CEA (immediate-range, 0-50%; delayed-range, 41-83%; P = 0.01). CONCLUSIONS: In the SoCal VOICe, 52% of patients undergo CEA within 2 weeks of symptoms. Increased stroke rates occur when CEA is performed within 2 days, whereas stroke and death rates are decreased at 3-14 days and beyond. These data support avoidance of immediate CEA. Opportunity exists to standardize timing of CEA for Sx-CAS among SoCal VOICe participants. Further study is required to define the role of immediate CEA.
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Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Infarto del Miocardio/etiología , Accidente Cerebrovascular/etiología , Tiempo de Tratamiento , Anciano , California , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/mortalidad , Bases de Datos Factuales , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Masculino , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery. METHODS: This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included. RESULTS: Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days. CONCLUSIONS: Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.
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Neoplasias de la Mama/cirugía , Colgajos Tisulares Libres/efectos adversos , Mamoplastia/efectos adversos , Piodermia Gangrenosa/etiología , Recto del Abdomen/trasplante , Adulto , Anciano , Neoplasias de la Mama/mortalidad , Neoplasias de la Mama/patología , Estudios de Cohortes , Manejo de la Enfermedad , Femenino , Estudios de Seguimiento , Colgajos Tisulares Libres/trasplante , Humanos , Mamoplastia/métodos , Mastectomía/métodos , Persona de Mediana Edad , Complicaciones Posoperatorias/patología , Complicaciones Posoperatorias/cirugía , Piodermia Gangrenosa/patología , Piodermia Gangrenosa/cirugía , Enfermedades Raras , Reoperación/métodos , Estudios Retrospectivos , Medición de Riesgo , Factores de Tiempo , Trasplante Autólogo/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) is a crucial therapy for sudden cardiac arrest (SCA), yet rates of bystander CPR are low. This is especially the case for SCA occurring in the home setting, as family members of at-risk patients are often not CPR trained. OBJECTIVE: To evaluate the feasibility of a novel hospital-based CPR education program targeted to family members of patients at increased risk for SCA. DESIGN: Prospective, multicenter, cohort study. SETTING: Inpatient wards at 3 hospitals. SUBJECTS: Family members of inpatients admitted with cardiac-related diagnoses. MEASUREMENTS AND RESULTS: Family members were offered CPR training via a proctored video-self instruction (VSI) program. After training, CPR skills and participant perspectives regarding their training experience were assessed. Surveys were conducted one month postdischarge to measure the rate of "secondary training" of other individuals by enrolled family members. At the 3 study sites, 756 subjects were offered CPR instruction; 280 agreed to training and 136 underwent instruction using the VSI program. Of these, 78 of 136 (57%) had no previous CPR training. After training, chest compression performance was generally adequate (mean compression rate 90 ± 26/minute, mean depth 37 ± 12 mm). At 1 month, 57 of 122 (47%) of subjects performed secondary training for friends or family members, with a calculated mean of 2.1 persons trained per kit distributed. CONCLUSIONS: The hospital setting offers a unique "point of capture" to provide CPR instruction to an important, undertrained population in contact with at-risk individuals.