PURPOSE To offer an educational experience that will help to improve the participant's understanding of the various types of nonsurgical debridement. TARGET AUDIENCE This CME/CE activity is intended for physicians and nurses with an interest in the prevention, diagnosis, and treatment of chronic wounds. LEARNING OBJECTIVES At the conclusion of this activity, participants should be able to: Describe the role of debridement in wound healing. Identify the different types of nonsurgical debridement. Summarize the benefits and limitations of the different types of nonsurgical debridement. Identify wounds that should not be debrided.

An aneurysm of the pancreaticoduodenal artery was identified in a 60-year-old woman with the primary complaint of epigastric pain that radiated through to her back. A computerized tomography (CT) scan with contrast established the initial diagnosis; an angiogram confirmed the diagnosis and vascular anatomy. The aneurysm was opened and a reverse saphenous vein reestablished circulation.

Two cases of limited infrarenal abdominal aortic dissection are reported. One patient was treated successfully with medical therapy alone, which resulted in complete resolution of symptoms and obliteration of the dissection. The second patient continued to have pain and eventually required aortic graft replacement. Abdominal aortic dissection may be an entity different from thoracic aortic dissection.

Technologic advancement has provided earlier detection and confirmation of aortic aneurysms, fewer physicians seemingly relying on their clinical skills to diagnose abdominal aortic aneurysms. Of 145 infrarenal aortic aneurysms, analysis disclosed that less than 30% were clinically discovered on admission. Fifty-six aortic aneurysms were discovered incidentally, most often during an annual physical examination in the course of evaluation for another problem. Aneurysms measuring less than 4.5 cm were rarely discovered on physical examination. The majority of both clinically discovered and inci dental aneurysms ranged between 5.5 and 6.0 cm. Ultrasound identified most aneurysms. The size of an aneurysm did not appear to have a role in determining whether it was discovered clinically.

Vein graft stenosis is a precursor to graft failure and its management is controversial. The authors reviewed their experience with percutaneous transluminal angioplasty (PTA) for these lesions. Thirty-one infrainguinal vein grafts (30 patients) underwent 59 PTAs at 44 different sites. Mean patient age was 66.7 years, and 17 (57%) were men. Hemodynamically significant lesions (>50% diameter reduction) were established by duplex scan or angiography. All patients had follow-up duplex graft surveillance. Determination of recurrence was based on duplex criteria (peak systolic velocity >200 cm/sec, velocity ratio >2). PTA outcomes at 3 months were divided into successful and unsuccessful categories. Eight stenoses were excluded from this assessment secondary to follow-up < 3 months. All bypass grafts were patent through their last evaluation. Ninety percent of lesions (46/51) received adequate initial dilations. The successful group (41/51 lesions, 80%) had a mean follow-up of 10.8 months (range 3.0-26.3). In this group, 12 lesions recurred with a mean time from PTA of 5.3 months (range 3.0-13.6). Of the 10 unsuccessfully treated lesions, five were angioplasty failures and five recurred within 3 months. The distal anastomosis was the most unsuccessful location to be treated (P=0.01). The length of the lesions and the age of the graft did not influence outcome (P>0.05). There were two complications from PTA: an occlusion effectively treated with thrombolytic therapy and one distal embolization. In conclusion, 80% (41/51) of stenoses treated with PTA were successful for at least 3 months. Two thirds of first-time lesions were stenosis-free at 1 year. PTA is a safe, reasonable method for the management of vein graft stenosis. The distal anastomosis is the most difficult site to manage.

Chronic venous insufficiency (CVI) with associated venous hypertension may lead to stasis dermatitis and ulceration. This sixty-month study determined whether compliance with the use of below-the-knee graduated-compression hosiery affected long-term clinical manifestations. At one year, 105 patients of 284 (37%) were compliant and 179 (63%) were not. At 2 pears, of the available compliant patients (89), none had skin changes; 28% of the available (51) noncompliant patients had skin changes; and 13 of this group (51) had ulceration. At sixty months, of 79 compliant patients available, none had ulceration and 11 had stasis changes, Of noncompliant patients (119) available for assessment, 63 (53%) have chronic skin changes. Compliance with the use of gradient compression below-the-knee stockings reduces the incidence of venous stasis disease and ulceration.

Abdominal aortic aneurysms have been a rare finding in patients who have previously undergone renal transplantation. Previous operative strategies attempting to provide renal allograft protection during aortic cross-clamping have included extra-anatomic permanent as well as temporary bypass, heparin bonded shunts, in situ perfusion cooling of the allograft, and general hypothermia. These maneuvers, although generally successful, have recently been challenged by reports describing no specific protective measures. A case of a 5.0 cm but rapidly expanding abdominal aortic aneurysm in a patient who had undergone a prior successful kidney transplant is presented along with a literature review of 27 available cases on the subject.

This case report details a patient treated for a gangrenous toe by angioplasty, sympathectomy, and aortobifemoral grafting who arrived at the hospital with acute renal dysfunction and an occluded bypass graft. The patient had no abnormal results from coagulation studies and no absolute contraindications to urokinase therapy but died from intracranial hemorrhage. The authors believe that hemostatic system impairments related to renal dysfunction act synergistically with thrombolytic agents to produce abnormal bleeding. This case report suggests a synergistic interaction between acute renal dysfunction and urokinase therapy.

Patients with extensive lower extremity ulcerations initially thought to be vascular disease were subsequently proved to have pyoderma gangrenosum and malignant lymphoma. Both patients died of sepsis; one patient exhibited hypogammaglobulinemia involving immunoglobulins IgA, IgG, and IgE; in the second patient, a polyclonal excess involving IgA and IgE was present.

This is a report of familial aortic dissection in a mother and son with no evidence of Marfan's syndrome in either patient. The mother, a fifty-three—year-old nurse, was evaluated initially for a four-year history of untreated hypertension and heart murmurs. Multiple cardiac complaints, including shortness of breath and chest pain on exertion, with a strong smoking history associated with an Austin-Flint murmur were noted. Subsequent laboratory studies, including electrocardiogram and cardiac catheterization, confirmed the diagnosis of dissection in the ascending aorta with free communication with an aneurysmal sac. Operative intervention included a Dacron prosthesis and porcine xenograft for aortic valve replacement. The postoperative course is unremarkable and the patient remains well after eleven years. Her twenty- eight-yearold son had a heart murmur identified on an office visit for a recurrent upper respiratory infection. Increased symptoms of shortness of breath, pulsus bisferiens, and an Austin-Flint murmur, along with findings on electrocardiogram and subsequent cardiac catheterization, confirmed the diagnosis of dissecting aortic aneurysm. The patient did not tolerate surgical intervention and a supraventricular tachycardia resulted in his death. Autopsy confirmed the extent of dissection, a 630-g heart with biventricular dilatation, hypertrophy, and dilatation of the atria; there was extensive cystic medial necrosis in the aorta. Marfan's syndrome is excluded because of the genetic predisposition to dissecting aortic aneurysm and no other findings of the Marfan's syndrome were identified. This report is to document the genetic predisposition and identification of 2 cases of congenital aortic dissection and its consequences.

We wanted to determine the long-term effects of a continuous infusion of PGE1 on DO2 and VO2 in patients with ARDS. Data were obtained from a randomized double-blind multicenter trial, which evaluated the effects of PGE1 on survival in patients with ARDS. Patients were stratified according to treatment and outcome: placebo-died (n = 8); PGE1-died (n = 12); placebo-survived (n = 9); and PGE1-survived (n = 8). In the placebo-died group, elevations occurred in VO2, which were associated with increases in O2ext and a constant DO2. In contrast, in the PGE1-died group, elevations in VO2 were associated with increases in DO2 and an unchanged O2ext. In the placebo-survived group, VO2 and DO2 decreased, whereas in the PGE1-survived group, VO2 and DO2 increased; however, O2ext decreased in both of these groups. Since impaired O2ext occurs in ARDS, PGE1-induced elevations in DO2, rather than compensatory increases in O2ext, may achieve better tissue oxygenation. We conclude that although the recently completed multicenter trial failed to show an enhancing effect of PGE1 on survival in patients with advanced ARDS, PGE1 may have important effects on oxygen transport and, therefore, may still have a role in the treatment of early manifestations of ARDS, either alone or in combination with other agents.

We wanted to determine the long-term effects of a continuous infusion of PGE1 on DO2 and VO2 in patients with ARDS. Data were obtained from a randomized double-blind multicenter trial, which evaluated the effects of PGE1 on survival in patients with ARDS. Patients were stratified according to treatment and outcome: placebo-died (n = 8); PGE1-died (n = 12); placebo-survived (n = 9); and PGE1-survived (n = 8). In the placebo-died group, elevations occurred in VO2, which were associated with increases in O2ext and a constant DO2. In contrast, in the PGE1-died group, elevations in VO2 were associated with increases in DO2 and an unchanged O2ext. In the placebo-survived group, VO2 and DO2 decreased, whereas in the PGE1-survived group, VO2 and DO2 increased; however, O2ext decreased in both of these groups. Since impaired O2ext occurs in ARDS, PGE1-induced elevations in DO2, rather than compensatory increases in O2ext, may achieve better tissue oxygenation. We conclude that although the recently completed multicenter trial failed to show an enhancing effect of PGE1 on survival in patients with advanced ARDS, PGE1 may have important effects on oxygen transport and, therefore, may still have a role in the treatment of early manifestations of ARDS, either alone or in combination with other agents.

This study assessed the compliance useage and impact by monitoring of graded compression hosiery in chronic venous disease. Diagnostic methods, such as qualitative photoplethysmography (PPG), have enabled the physician to assess deep-vein valvular incompetence earlier and begin specific treatment measures to slow the progression of symptoms. This study group, comprised of 100 patients, was diagnosed initially with deep-venous thrombophlebitis and evaluated by phleborrheography and PPG at three-month intervals for one year. The patients were instructed to wear fitted, graded compression hosiery after hospital discharge; compliance was 37% at one year. The primary reason for noncompliance was socioeconomic. The price of the ideal graded compression hosiery was not easily within reach of this population and insurance reimbursement was difficult or impossible to obtain. Complaint patients felt better while wearing the compression hosiery. Increasing deterioration of qualitative PPG values of deep-valve assessment was found in both compliant and noncompliant patients at each testing interval. The PPG value deteriorated as time increased with or without the compression hose, although symptoms lessened when the prescribed hosiery was worn. The long-term sequelae of wearing or not wearing the hosiery are yet to be determined, but PPG assessment is normalized with the hosiery in place.

Prostaglandin E1 (PGE1) was compared to placebo in a 100-patient (50 PGE1, 50 placebo) randomized, double-blind, clinical trial to determine whether PGE1 therapy enhances survival of patients with adult respiratory distress syndrome (ARDS) when infused through a central line at 30 ng/kg/min continuously for seven days. At 30 days postinfusion, 30 PGE1 and 24 placebo patients had died. Total deaths judged to be related to the syndrome were 32 and 28 in the PGE1 and placebo groups respectively at six months. We conclude that PGE1 did not enhance survival in patients with established ARDS. PGE1 augmented the hyperdynamic circulation of these patients by reducing systemic and pulmonary vascular resistance, which resulted in a reduction of blood pressures and increased stroke volume, cardiac output, and heart rate. An improvement in oxygen availability and oxygen consumption was observed with PGE1 therapy. PGE1 was associated with an increased incidence of diarrhea (six patients in the PGE1 group vs one in the placebo group, p less than 0.05). Other adverse effects included hypotension (ten patients in the PGE1 group vs seven in the placebo group), fever (six patients in the PGE1 group vs three in the placebo group), and non-fatal dysrhythmias (ten in the PGE1 group vs five in the placebo group).

Patients with established adult respiratory distress syndrome (ARDS) have a mortality rate that exceeds 50 percent. We analyzed the magnitude of hypoxemia as manifest by the PaO2/FIO2 ratio and its early response to conventional therapy including positive end-expiratory pressure (PEEP) in the placebo group of a large multicenter study. The PaO2/FIO2 ratio was not different at the time of diagnosis of ARDS in those patients who lived compared to those who subsequently died. After one day of conventional therapy including PEEP, those patients who survived increased their PaO2/FIO2 ratio. The nonsurvivors did not improve over a seven-day course. The difference in the PaO2/FIO2 ratio was significant throughout the seven-day observation period. We conclude that the early response to conventional therapy picks a patient population with a good prognosis and can be used as a test of likely survival from ARDS.

Ulcerative lesions appearing on a below-the-knee (BK) stump often delay permanent prosthesis fitting and rehabilitation or prevent the user of a perma nent prosthesis from resuming the ambulatory state. Seventeen patients (11 men, 6 women), with an average age of 61.4 (range 52 to 71) years, had under gone BK amputation for vascular disease (rest pain or gangrene, or both, with ankle:brachial index ratios < 0.15); 5 patients (3 men, 2 women) had diabetes controlled with insulin. All patients had a history of smoking with associated cardiovascular disease determined by physical examination or electrocardio gram, or both. Fourteen patients did not have initial healing after their BK amputation; the other 3 had a BK amputation in the distant past (twelve, eight een, and twenty months previously) and a nonhealing ulcer. All patients were referred for revision to an above-the-knee (AK) amputation; none came to AK amputation. All patients were treated with intravenous cephalosporins, de bridement, whirlpool, fine mesh gauze dressings, and a softstem air splint. The air splint prosthesis allowed proprioception, balance, gait, and total contact compression at 25 mm Hg when ambulatory. All wounds healed in fourteen to twenty-four days, allowing return to the permanent prosthesis in 3 patients and early measurement and fitting (no delay) of the remaining 14 patients for a permanent prosthesis. The softstem air splint temporary prosthesis represents an adjunctive measure in management of a nonhealing lesion on the stump of a BK amputee. It can facilitate rehabilitation via maintenance of gait, pro prioception, balance, and shape.

Ten patients (eight men, two women) with a mean age of 61.8 years were operated on for atherosclerotic vascular disease or abdominal aortic aneurysm and had subsequent placement of Polytetraflourethylene (PTFE) bifurcation grafts. Follow up by the life table method at nearly five years reflects all patent grafts. We conclude the PTFE vascular grafts are an acceptable alternative to the current methodology in the aortofemoral position.

A 51-year-old female presented with axillary-subclavian vein effort throm bosis. The treatment modality was low-dose constant-infusion streptokinase, followed by heparin and coumadin. Near-total resolution of the pathology and symptoms resulted. There were no adverse events secondary to streptokinase.