The ideal balloon inflation time in balloon angioplasty remains unknown. There are theoretic benefits for a prolonged inflation time in peripheral vessels, including reduced intimal trauma and recoil, but studies have been inconclusive. Our research compared the arterial response to prolonged inflation time (3 minutes) and standard inflation time (30 seconds) in a rat aortic angioplasty model. Male Wistar rats were given vitamin D3, nicotine, and an atherogenic diet with added cholesterol and cholate. After 2 months, each rat received angioplasty of its distal aorta held for 30 seconds or 3 minutes. The rats were euthanized at 24 hours or 30 days, and aortas were assessed for comparison of intimal disruption in the 24-hour group or amount of intimal hyperplasia and medial thickening in the 30-day group. After 24 hours, both inflation time groups showed mild intimal disruption, but the difference in wall disruption scores was not significant. At 30 days, lumen and outer wall diameters showed no significant differences between groups. There were no significant differences in intimal wall areas. The intimal and medial wall area as a percentage of overall vessel area was 35.0% ± 5.2% in the 30-second group and 36.8% ± 6.6% in the 3-minute group, which was not significant. Prolonged balloon inflation time failed to produce significant changes in intimal disruption after 24 hours. At 30 days, there was no difference in the amount of intimal hyperplasia, medial wall thickening, or lumen diameter compared with standard inflation times.

Background: Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat. Patients with an ankle-ebrachial index (ABI) of 0.5-0.8 have been shown to heal poorly. Because adequate compression therapy is contraindicated in patients with an ABI of <0.7, we decided to undertake an aggressive approach of percutaneous revascularization for these patients.Methods: A total of 27 patients with clinical and duplex scan evidence of chronic venous insufficiency, active leg ulcers, and impaired arterial perfusion (ABI: <0.7) were treated using a protocol that required performing percutaneous revascularization before ambulatory compression therapy. The patients were followed at 2-week intervals (average) before and after revascularization. Wound measurements and time to complete closure were also recorded.Results: The results of the patients were compared with their own previous wound healing trajectories. Additionally, their healing rate was compared with previously published rates of impaired arterial perfusion venous wound closure; 25% closure at 10 weeks, 50% at 19 weeks. At enrollment, the average ABI and wound sizes were 0.56 and 12 cm(2), respectively. On average, the wounds had remained open for 17 weeks. After the intervention, the average ABI was 0.97, average time taken to complete closure was 10 weeks, closure rate at 10 weeks was 75%, and absolute closure rate was 100%.Conclusion: Although previous studies have shown that closure of mixed arterial venous ulcers occur without arterial intervention, attaining a near normal ABI allows for timelier wound closure. Therefore, we advocate an aggressive approach of percutaneous revascularization in this population.

les ulcères veineux actifs chez les patients avec insuffisance artérielle et veineuse associées sont notoirement difficile à traiter. Des patients présentant un index bras-cheville (IBC) de 0,5-0,8 ont connus pour mal guérir. Comme le traitement par compression est contre-indiqué chez les patients avec un IBC < 0,7, nous avons décidé d’adopter une approche agressive de revascularisation percutanée pour ces patients. Un total de 27 patients présentant selon des critères cliniques et écho-doppler une insuffisance veineuse chronique, des ulcères de jambe actifs, et une perfusion artérielle altérée (IBC: < 0,7) ont été traités en employant un protocole qui a exigé une revascularisation percutanée avant traitement ambulatoire par compression. Les patients ont été suivis à intervalles de deux semaines (moyenne) avant et après la revascularisation. Des mesures de la plaie et le temps de cicatrisation ont été également enregistrés. Les résultats des patients ont été comparés à l’évolution antérieure de leur plaie. De plus, leur taux de cicatrisation a été comparé aux taux précédemment publiés de cicatrisation d’ulcères veineux avec perfusion artérielle altérée; taux de cicatrisation de 25% à 10 semaines, 50% à 19 semaines. A l’inclusion, les IBC et les tailles des lésions moyens étaient de 0,56 et de 12 cm2, respectivement. En moyenne, les lésions étaient restées ouvertes pendant 17 semaines. Après l’intervention, l’IBC moyen était de 0,97, le temps moyen de cicatrisation complète était de 10 semaines, le taux de cicatrisation à 10 semaines était de 75%, et le taux absolu de cicatrisation était 100%. Bien que les études précédentes aient prouvé que la fermeture des ulcères veineux avec composante artérielle se produisent sans intervention artérielle, l’obtention d’un IBC presque normal permet de raccourcir le délai de cicatrisation. Par conséquent, nous préconisons une approche agressive de revascularisation percutanée dans cette population.

PURPOSE: Sphincter-sparing chemoradiotherapy (CRT) is the standard of care for patients with anal canal cancer.Despite good response rates, some patients require radical surgery (abdominoperineal resection or exenteration)for persistent or recurrent disease.The purpose of this study was to evaluate the outcomes of patients following radical resection for persistent or recurrent disease.METHODS: All patients treated with CRT or RT for anal cancer between 1990 and 2008 were identified using the regional cancer registry.Inclusion criteria: pathologically confirmed squamous cell carcinoma of the anal canal, localized disease, receiving ≥ 45Gy of RT.Statistical analysis was conducted to calculate survival rates and identify risk factors for poor outcomes.RESULTS: 105 patients (25 male) were identified.Median age was 57 years (range 33-87 yr).Median follow up was 40 months (range 3-185).Median T stage and size at presentation were 2 and 35 mm (range 6-260mm) respectively.Median dose to the primary tumor was 54 Gy (45-76 Gy) at a median 28 fractions (range 20-37).92 patients(88.5%)received concurrent chemotherapy.At 3 month followup 85 (83.3%) patients had complete clinical response, one patient had insufficient followup.19 (18.1%) patients had persistent disease, of whom 12 underwent radical resection for cure; 5 (41.7%) are alive at a median of 106 months from diagnosis, while the remaining 7 died at a median 15 months from diagnosis.Recurrence occurred in 17 (20.0%) patients at a median time of 9 months (4-53m).8 patients underwent radical resection for recurrence; 2 (25.0%) patients are alive at 127 and 21 months, the remaining 6 died at a median time from recurrence of 24.5 months.Overall, disease specific and disease free survival, were 66%, 71% and 67% respectively for all anal canal carcinoma patients at 5 years.Multivariate analysis showed tumor size to be a significant risk factor for disease free (aOR 1.02, 95% CI: 1.01-1.04)and overall survival (aOR 1.03, 95% CI: 1.01-1.04)for all patients.CONCLU-SION: Despite good response rates to sphincter-sparing therapy, 20% still required radical resection for persistent or recurrent disease.Survival rates following radical resection are poor.

The ideal balloon inflation time in balloon angioplasty remains unknown. There are theoretical benefits for a prolonged inflation time, including reduced intimal trauma and recoil, but studies have been inconclusive. Our research aims to compare prolonged and standard inflation time in a rat aortic angioplasty model. Male Wistar rats were given Vitamin D3 and nicotine, a regimen previously found to produce arteriosclerosis in rats, and fed an atherogenic diet with added cholesterol and cholate. After two months, each rat received distal aortic angioplasty with a 2mm x 8mm standard angioplasty balloon at nominal pressure. Inflation was held for either 30 seconds (standard time) or three minutes (prolonged time). The rats were sacrificed at 24 hours (six rats, three per time group) or 30 days (ten rats, five per group), and aortas were assessed histologically, with comparison of intimal disruption in the 24-hour group and comparison of lumen and wall areas, amount of intimal hyperplasia and medial thickening in the 30-day group. After 24 hours, both inflation time groups showed mild intimal disruption, but the difference in wall disruption scores was not significant. At 30 days, lumen and outer wall diameters were, respectively, 1.20 +/−0.07mm and 1.41 +/−0.05mm in the 30-second time group, and 1.05 +/−0.11mm and 1.24 +/−0.09mm in the 3-minute time group (p NS between groups). Intimal hyperplasia was modest in all rats, with no significant differences in intimal wall areas. The intimal and medial wall area as a percentage of overall vessel area was 35.0 +/−5.2% in the 30-second group and 36.8 +/−6.6% in the 3-minute group (p NS). Prolonged balloon inflation time failed to produce significant changes in intimal disruption after 24 hours. At 30 days, there was no difference in the amount of intimal hyperplasia, medial wall thickening, or lumen diameter compared to standard inflation times. These results do not support changing current balloon angioplasty practices.

UNLABELLED: Abstract: Negative pressure wound therapy (NPWT) has consistently shown significant clinical benefits in wound healing, but the mechanisms are not fully elucidated. While a reduction in bacterial burden is one possible contributor, studies have shown mixed results in this regard. The present study used a porcine infected wound model to test the effect of NPWT on bacterial burden.METHODS:Infected wounds (Pseudomonas aeruginosa, coagulase negative Staphylococcus, and Bacteroides fragilis) in a porcine model were treated with V.A.C.® therapy with the standard GranuFoam™ dressing, V.A.C. therapy with the GranuFoam Silver® dressing, or moist gauze for a period of 7 days with three dressing changes. Quantitative and semiquantitative bacterial cultures, histological samples, and digital photographs were taken at dressing changes.RESULTS:The wounds continued to show gross and microscopic improvement when treated with standard NPWT and NPWT with silver compared to moist wound care controls. However, the bacterial burden in all wounds continued to increase and broadened to include local skin flora, which had been absent immediately after wounding. These increases in bacteria were not affected by the use of silver dressings.CONCLUSION:Negative pressure wound therapy with either standard NPWT foam or silver NPWT foam produced significant improvements in local wound appearance. This occurred despite a persistently high level of bacterial infection; thus, the improvement in healing of these infected wounds cannot be explained by a change in the bacterial burden. .

Razi, Syed Shahzad MD; Schwartz, Gary MD; Boone, Deva MD; Belsley, Scott MD, FACS; Todd, George MD, FACS; Connery, Cliff P. MD, FACS; Bhora, Faiz Y. MD, FACS Author Information

We examined the effects of extracoronary artery disease on postoperative complications, 30-day mortality, and long-term mortality after coronary artery bypass grafting (CABG). We reviewed 4766 patients who underwent CABG at a single institution between 1992 and 2008. Preoperative and intraoperative risk factors and postoperative complications were collected prospectively for our state cardiac surgery database. Long-term survival data (mean follow-up 8.3 years) were obtained from the National Death Index. Risk factors for postoperative complications and 30-day mortality were determined by multivariate logistic regression analysis and predictors for long-term mortality were determined by multivariate Cox regression analysis. Risk-adjusted Kaplan-Meier curves were constructed and compared using the log-rank test. Of all patients undergoing CABG, 513 patients (10.8%) had carotid artery disease and 563 patients (11.8%) had peripheral vascular disease (PVD). Just 162 patients (3.4%) had both conditions. Postoperative complications occurred in 11.0%, with the most common complication being respiratory failure. After adjusting for other risk factors, PVD remained an independent predictor for postoperative complications (OR 1.42, 95% CI 1.10-1.82, p = 0.008), but carotid disease did not. Thirty-day mortality overall was 7.3%; neither carotid disease nor PVD were associated with increased 30-day mortality after adjusting for other risk factors. After ten years, survival for patients without carotid disease or PVD was 70%; survival was 42% for those with carotid disease and 38% for those with PVD. After risk-adjustment, both carotid disease (HR 1.19, 95% CI 1.04-1.36, p = 0.01) and PVD (HR 1.41, 95% CI 1.24-1.61, p < 0.001) remained independent predictors of long-term mortality. While neither carotid disease nor PVD were associated with 30-day mortality, both were independent predictors of long-term mortality after CABG. Only PVD was associated with increased postoperative complications.

Razi, Syed Shahzad MD; Schwartz, Gary MD; Li, Xiaogui PhD; Boone, Deva MD; Belsley, Scott MD, FACS; Todd, George MD, FACS; Connery, Cliff P. MD, FACS; Bhora, Faiz Y. MD, FACS Author Information

Endoscopic tracheoplasty is used for the relief of airway obstruction because of several benign conditions such as postintubation stenosis, inflammatory disorders such as Wegener granulomatosis, and benign neoplastic processes. Several endoscopic treatment modalities exist for these conditions, all with good initial results. However, recurrence is common and often requires frequent reintervention. Endoscopic segmental tracheal ring resection is a novel therapeutic approach that could potentially provide a durable solution. Endoscopic segmental tracheal ring resection was performed in 3 Yorkshire pigs under general anesthesia. A combination of bipolar cautery and sharp dissection was used to resect 25% to 33% of the circumference of a single tracheal ring. Technical success was achieved in all 3 animals with no intraoperative complications. Full-thickness excision, including the anterior perichondrium, was performed in 1 animal without violation of the pretracheal fascia, with no subcutaneous emphysema or clinically apparent pneumothorax. Average operative time was 31 minutes and estimated blood loss was minimal. Heart rate, oxygen saturation, and peak airway pressures were maintained within normal ranges during the procedure and for the 60-minute postoperative period. Histologic analysis of the resected specimen confirmed complete thickness excision of the segment of tracheal cartilage. Endoscopic tracheoplasty by segmental tracheal ring resection is a safe and feasible technique in a porcine model. Long-term durability could potentially outlast other endoscopic techniques for the treatment of bening tracheal stenosis. Survival studies in a porcine model of tracheal stenosis must be performed to assess the long-term outcomes of this approach.

INTRODUCTION:The 2-year cost of a new diabetic foot ulcer (DFU) is estimated to be $27,987. These costs are thought to be secondary to hospitalization, amputation, and the duration of care. Treatments that accelerate rapid and complete healing of DFUs reduce the need for hospitalization, thus reducing the costs of care. One of the therapies previously shown to lead to more rapid and complete wound healing of DFUs is recombinant human platelet-derived growth factor (rhPDGF). Many centers, however, do not initiate rhPDGF therapy, based on patient cost issues. Therefore, many centers reserve a potentially cost-saving therapy as a second- or third-line therapy. The goal of the authors' analysis was to examine the actual cost to patients of a policy of initiating rhPDGF as the initial therapy for appropriately debrided DFUs.METHODS:A 12-month retrospective analysis of all patients presenting to a tertiary care referral wound practice with the diagnosis of DFUs was performed. The algorithm the authors followed specified that all wounds of patients with an ankle brachial index of greater than 0.7 and a diagnosis of DFUs (that were not enrolled in a research protocol) were debrided widely (ie, all wounds were debrided sharply with a 45-degree bevel on the border and the bases of the wounds were sharply debrided to a clean granular base), provided off-loading, and initiated on rhPDGF at the patients' first center visit. The patient payer mix and average cost-per-patient per year were analyzed, and the average number of tubes of rhPDGF was recorded.RESULTS:There were 121 patients with the diagnosis of DFUs, representing 766 visits. A total of 187 tubes of rhPDGF were prescribed for these 121 patients over the course of 12 months. There was an average use of 1.54 tubes per patient. The primary payer mix was Medicare, 44%; Medicaid, 27%; and private-payer mix, 29%, representing 10 companies. The average patient cost per tube was $28, the average cost for Medicare was $25 (many with secondary payers, as data predate 2006 Medicare D), Medicaid was $2, and private insurance was $71. Therefore, the average patient cost per course of therapy was $42.DISCUSSION:The average cost to patients with prescription benefits for a course of rhPDGF therapy, over a diverse and representative patient mix, is less than $50 in an inner-city tertiary care facility. Thus, patient cost alone should not provide a barrier to initiating active therapy in the form of rhPDGF to the patient presenting with a DFU. This early initiation could potentially lead to lower overall health costs by improving wound-healing outcomes.