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At any point in time, 3% to 4% of the 29.1 million diabetic patients in the United States (9.3% of the population) will have a foot ulcer. Diabetes-associated foot ulcers and infection lead to >70,000 lower-extremity amputations yearly in the United States. Between one-third and one-half of diabetic patients undergoing a major lower-extremity amputation will die within 2 years after the amputation. Multidisciplinary population health-management strategies have been developed to decrease the rate and magnitude of this important comorbidity in the diabetic population. The goal of the present review is to provide the reader with a framework for the development of a health-care-system strategy for addressing this complex patient population.

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PURPOSE: We describe a case of severe acute pancreatitis after percutaneous mechanical thrombectomy (PMT) and review the literature for the occurrence of this complication. MATERIALS AND METHODS: A 53-year-old man with a history of bilateral external iliac artery stent placement sought care for acute onset of lifestyle-limiting left claudication. Angiography confirmed left external iliac stent occlusion, and PMT with the AngioJet Xpeedior catheter (Possis Medical, Minneapolis MN) was performed. RESULTS: After PMT of the occluded external iliac artery, a residual in-stent stenosis required the placement of a second iliac stent. The procedure was complicated by severe acute pancreatitis. Other causes of pancreatitis were eliminated during the patient's hospital stay. A literature review revealed nine cases of acute pancreatitis after PMT. CONCLUSION: Although rare, pancreatitis can be a devastating complication of PMT. The development of pancreatitis seems to be related to the products of extensive hemolysis triggering an inflammatory process. To prevent this complication, we recommend that close attention be paid to the duration and extent of PMT, thereby avoiding extensive hemolysis and subsequent complications.

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Renal vein aneurysms are exceedingly rare. There are only 8 reported cases in the literature. We present the first case of a renal vein aneurysm discovered incidentally during a laparoscopic radical nephrectomy and discuss its intraoperative management.

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BACKGROUND: Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times. METHODS: A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma. RESULTS: In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%. CONCLUSION: The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

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Scant data exist regarding patient outcome after treatment of abdominal compartment syndrome (ACS) with decompressive laparotomy. This work reviews the outcome of 25 burn patients at a single institution who underwent decompressive laparotomy for treatment of ACS in the periresuscitation period. A computerized burn registry and directed chart review were used for data collection and analysis in this retrospective review. From September 1996, 25 patients underwent decompressive laparotomy after developing ACS. Mean burn size was 65 +/- 19% TBSA. Mean age was 28 +/- 19 years. Twenty-two (88%) died. Myo/ hemoglobinuria was present at admission in eight patients, one of whom survived. Fourteen patients had inhalation injury, of whom two survived. Before decompressive laparotomy, mean bladder pressure and peak inspiratory pressure were 57 +/- 4.2 mm Hg and 41 +/- 2.2 mm Hg, respectively. Mean urine output improved from 28 ml/hr to 90 ml/hr after decompressive laparotomy. The mean Ivy score was 443 +/- 34.95 ml/kg. Development of ACS in burn patients is associated with a high mortality. With development of IAH, therapeutic maneuvers such as sedation and paralysis, escharotomies, or changes in fluid management can be performed in hopes of altering the evolution of intra-abdominal hypertension to ACS. In patients with >40% TBSA burns, bladder pressures should initially be measured every 6 hours. When the Ivy score reaches 200 ml/kg, measure bladder pressures hourly. Decompressive laparotomies should be performed in all patients with ACS if less-invasive maneuvers fail.

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