Amputation in diabetic patients.

in Clinics in Podiatric Medicine & Surgery (2007), 24(3), 569-82

In diabetes-related amputations, the risk of nonhealing or infection of a wound and the need for revision are increased. Medical treatment before amputation should optimize general and local conditions ... [more ▼]

In diabetes-related amputations, the risk of nonhealing or infection of a wound and the need for revision are increased. Medical treatment before amputation should optimize general and local conditions including the regression of edema, the control of infection, and the optimization of glucoregulation. A major argument for foot-sparing surgery is the poor functional recovery after major limb amputation. Diabetic patients are frail, with an increased postoperative morbidity and mortality after major amputation. Factors detrimental to functional outcome are advanced age, end-stage renal disease, dementia, and above-knee amputation. A multidisciplinary approach is required to optimize the results of diabetes-related amputations. The authors discuss medical and technical aspects that may reduce the failure of minor or major diabetes-related amputations. [less ▲]

Retour sur les dilatations-stenting des carotides

in Revue Médicale de Liège (2006), 61(10), 697-704

Recent publications about carotid-stenting are submitted to a critical analysis. The fact that an interventional approach in asymptomatic carotid lesions generates only marginal benefit being universally ... [more ▼]

Recent publications about carotid-stenting are submitted to a critical analysis. The fact that an interventional approach in asymptomatic carotid lesions generates only marginal benefit being universally admitted, it is disturbing to see that modern series devoted to carotid artery stenting include a lot of asymptomatic patients and many symptomatic patients with a degree of stenosis well below the optimal range defined in NASCET (70 to 99%). Moreover, the degree of stenosis is often calculated from an inappropriate method that overestimates the degree of stenosis. Two objections have been made about an "hyper-selection" of the patients enrolled in the NASCET study and the production of ideal not realistic results, not attainable in community hospitals; both objections have been overruled. The rate of acute perioperative myocardial infarction is mentioned, both in NASCET and ECST, it is around 0.9% vs 7.5% in SAPPHIRE study. Moreover, carotid artery stenting with an embolic protection device has resulted in the production of infra-clinical cerebral micro-infarcts in 40% of the patients. Significantly, the independent study EVA-3S, devoted to symptomatic patients had to be stopped because of the high cerebral morbidity in the dilatation-stenting group. Carotid artery stenting of asymptomatic lesions is futile (and potentially harmful because of microinfarcts) while carotid artery stenting of symptomatic lesions generate emboli. [less ▲]

Lessons learnt from carotid artery trials

in Acta Chirurgica Belgica (2006), 106(5), 489-499

The objective of the authors is to assess the natural history of carotid artery disease and the role of carotid intervention in preventing ipsilateral stroke. The development of endovascular techniques ... [more ▼]

The objective of the authors is to assess the natural history of carotid artery disease and the role of carotid intervention in preventing ipsilateral stroke. The development of endovascular techniques for correction of carotid artery stenoses made this less invasive technique very popular, with an inherent risk of unregulated overuse by a variety of medical specialists, who are not always well informed on the natural history of carotid artery disease. It re-opened the discussion on the value of carotid endarterectomy for stroke prophylaxis. This ongoing debate offers the opportunity to distil evidence-based guidelines for the management of extracranial carotid artery stenoses. In recent papers, some authors expressed doubts on the validity and general applicability of the results of the pivotal randomised trials of carotid endarterectomy. The excellent results in terms of operative outcome and long term stroke prevention would, according to certain comments, not be attainable in routine practice. Another criticism of carotid endarterectomy is its higher operative morbidity in terms of cranial nerve lesions and myocardial infarctions, compared to endovascular procedures. This consideration is, for some authors, the main reason to espouse carotid artery stenting as a better alternative to carotid endarterectomy. Any evidence supporting this point of view is missing. The supposed equivalence or non-inferiority of carotid artery stenting is purely speculative. The aim of this review paper is to summarize the crude data of carotid surgery trials. The authors aim to answer four questions. For which lesions is carotid endarterectomy most beneficial ? Are the results of randomised carotid surgery trials biased by the selection of patients ? Is operative morbidity, other than stroke, under-estimated ? Is carotid artery stenting safe and efficacious ? An in-depth review with a critical analysis is made of recently published and on-going trials, comparing carotid surgery with percutaneous carotid angioplasty. [less ▲]

Le cas clinique du mois. Necrose du cuir chevelu revelatrice d'une arterite a cellules geantes (maladie de Horton)

in Revue Médicale de Liège (2006), 61(1), 5-7

Scalp necrosis is an uncommon manifestation of giant cell arteritis (GCA). In this paper, we report our experience with a 78-year old woman in whom extensive scalp necrosis developed as a complication of ... [more ▼]

Scalp necrosis is an uncommon manifestation of giant cell arteritis (GCA). In this paper, we report our experience with a 78-year old woman in whom extensive scalp necrosis developed as a complication of GCA. A left frontal defect (7 X 4 cm) involving full-thickness scalp was observed. The necrosis extended deeply, involving the epicranium and the outer table of the skull. The therapeutic approach included corticotherapy, anticoagulation and wound care. Severe wound infection (osteitis, subgaleal abscess) occurred, requiring prolonged antibiotherapy. Second intention healing was obtained using a conservative approach. During the healing process, areas of neovascularization developed beneath the exposed part of the outer table and the necrotic bone underwent resorption. [less ▲]

Analyse des resultats des principales etudes randomisees d'endarteriectomie carotidienne pour stenose asymptomatique

in Revue Médicale de Liège (2005), 60(10), 811-3

The authors analyse the ACAS (1997-93) and ACST (1993-2003) trials, comparing the best medical therapy vs endarterectomy of an asymptomatic 60 % or more stenosis of the internal carotid artery. The ACAS ... [more ▼]

The authors analyse the ACAS (1997-93) and ACST (1993-2003) trials, comparing the best medical therapy vs endarterectomy of an asymptomatic 60 % or more stenosis of the internal carotid artery. The ACAS trial does not reveal any benefit of surgery in preventing major stroke during follow-up (stroke rate 3.4% vs 6.02% in medical group, N.S.). Only by considering minor and major strokes together, a beneficial effect of carotid endarterectomy could be evidenced (5.9% stroke reduction at 5 years: 5.1% ipsilateral stroke at 5 years after surgery vs 11% stroke at 5 years under medical treatment). Indeed, following surgery, the stroke risk (ipsilateral) at 5 years attained 5,1% vs 11% following medical treatment of an asymptomatic internal carotid artery stenosis of 60-99%. The ACST trial, set up in 1993, aimed to assess the long-term result of carotid endarterectomy for asymptomatic 60-99% stenosis. Patients randomized for immediate surgery had a slightly more favorable outcome than those allocated to medical treatment. Absolute risk reduction of major stroke at 5 years was 2.5%. Overall, the benefit of operating an asymptomatic carotid artery stenosis is rather low (1% less stroke per year and less than 0.5% major stroke reduction per year). This positive result is obtained only if the operative stroke-death rate remains extremely low (<2.8%). The indication for operating asymptomatic carotid stenosis must be cautiously taken; age of the patient, degree of stenosis and surgeon's experience and results are to be considered. [less ▲]

L'ischemie aigue des membres: aspects cliniques, diagnostiques et therapeutiques

in Revue Médicale de Liège (2005), 60(4), 247-54

Acute lower limb ischemia, with sudden interruption of tissue perfusion, is a medico-surgical emergency. An early diagnosis is a prerequisite for optimal management. Diagnosis is mainly based on clinical ... [more ▼]

Acute lower limb ischemia, with sudden interruption of tissue perfusion, is a medico-surgical emergency. An early diagnosis is a prerequisite for optimal management. Diagnosis is mainly based on clinical data. Complementary investigations have a limited place, and should not unnecessarily delay the treatment. There are two categories of acute arterial, non-traumatic occlusion: embolism and thrombosis of an atherosclerotic vessel. The distinction between these two entities is not always evident, since ischemia can be the consequence of an arterial embolism in a diseased atherosclerotic artery. We discuss the clinical aspects and the causes of acute lower limb ischemia. The prognosis, outcome and therapeutic management are determined by the cause of the acute arterial obliteration. [less ▲]

Le cas clinique du mois. Revascularisation des artères fémorales à partir de l'aorte thoracique descendante après thrombose d'un pontage axillo-bifémoral

in Revue Médicale de Liège (2005), 60(1), 11-7

We report the case of a patient who had lower limb revascularization by a bypass graft originating from the decending thoracic aorta, after total thrombosis of an axillobifemoral bypass graft. The latter ... [more ▼]

We report the case of a patient who had lower limb revascularization by a bypass graft originating from the decending thoracic aorta, after total thrombosis of an axillobifemoral bypass graft. The latter had been performed for surgical repair of a secondary aorto-enteric fistula. We successively discuss the three particular apects of this observation: the secondary aortodigestive fistula, the axillobifemoral bypass and the bypass between the descending thoracic aorta and the femoral arteries. [less ▲]

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm

in Vascular Surgery (2005), 42

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully ... [more ▼]

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months’ follow-up). [less ▲]

Combined reconstruction of the diabetic foot including revascularization and free-tissue transfer

in Journal of Reconstructive Microsurgery (2004), 20(7), 511-517

Diabetic patients, presenting with both peripheral vascular disease and large soft-tissue defects, are too often treated by primary amputation. A combined revascularization and free-tissue transfer ... [more ▼]

Diabetic patients, presenting with both peripheral vascular disease and large soft-tissue defects, are too often treated by primary amputation. A combined revascularization and free-tissue transfer procedure can extend limb salvage in these patients. The authors report their experience over 4 years with 19 diabetic patients with peripheral vascular disease and large soft-tissue defects of the foot requiring free-tissue transfer. Although there was a 100 percent flap survival, early local wound problems occurred in three patients (16.6 percent). The recurrence rate was about 18.7 percent, but no complementary flap procedures were mandatory. With a mean follow-up of 38 months (range: 23 to 55 months), the limb salvage rate was 94.4 percent. Although there was one limb loss and one patient with ambulation difficulties, 16 patients (84.2 percent) were fully rehabilitated and were able to function independently. Despite a rather small series, this study confirms that in selected diabetic patients, a combined approach of vascular and reconstructive surgeons can reduce the limb amputation rate with acceptable complication rates. This combined approach offers major benefits to these patients, especially stable coverage and preservation of ambulation, and should always be considered before amputation. [less ▲]

Crural or pedal artery revascularisation for limb salvage: is it justified

in Acta Chirurgica Belgica (2004), 104(2), 148-157

With the ageing of population, the incidence of limb-threatening ischemia increases. In chronic critical limb ischemia, peripheral arterial occlusive disease almost always involves infrainguinal and ... [more ▼]

With the ageing of population, the incidence of limb-threatening ischemia increases. In chronic critical limb ischemia, peripheral arterial occlusive disease almost always involves infrainguinal and infragenicular vessels. Fortunately, recent advances in vascular surgery made arterial reconstruction of crural and pedal vessels possible. Should crural or pedal bypass surgery be offered to these frail, polyvascular patients, or is primary amputation a preferable treatment option in case of advanced limb-threatening ischemia? In order to answer this controversial question, the author analysed recent literature data on the feasibility and durability of infrapopliteal bypasses. The quality of life was also considered as an outcome measure. Finally, the cost-effectiveness of both treatment modalities (limb-saving distal bypass versus primary amputation) was assessed. [less ▲]