Martorell ulcer is a form of lower limb ulceration, preceded by a small area of excruciating pain. It often appears as a solitary lesion on the outer aspect of the lower limb, and is primarily associated with poorly controlled hypertension and diabetes. Treatment of the ulcer involves awareness and early correct diagnosis, adequate control of blood pressure, management of infection, and wound care. We describe a 77-year-old diabetic and hypertensive woman presenting with excruciating pain in her right lower lateral leg leading to a necrotic ulcer. Serial photographs of the evolution of the lesion and eventual healing of the ulcer are presented.
Covered Endovascular Reconstruction of Aortic Bifurcation (CERAB) is a new technique to treat extensive aortoiliac occlusive disease with covered expandable stent grafts to rebuild the aortoiliac bifurcation. Post stenting Doppler ultrasound (DUS) measurement of maximum peak systolic velocity (PSV) in the stented segment is widely used to determine patency and for follow up surveillance due to the portability, affordability and ease of use. Anecdotally, changes in hemodynamics created by CERAB can lead to falsely high PSV requiring CT angiography (CTA) for further assessment. Therefore, the importance of DUS would be enhanced with a proposed PSV prediction tool to ascertain whether PSV falls within the acceptable range of prediction. We have developed a prediction tool based on idealized models of aortoiliac bifurcations with various infra-renal PSV (PSV), iliac to aortic area ratios (R) and aortoiliac bifurcation angles (α). Taguchi method with orthogonal arrays (OA) was utilized to minimize the number of Computational Fluid Dynamics (CFD) simulations performed under physiologically realistic conditions. Analysis of Variance (ANOVA) and Multiple Linear Regression (MLR) analyses were performed to assess Goodness of fit and to predict PSV PSV and R were found to contribute 94.06% and 3.36% respectively to PSV. The Goodness of fit based on adjusted R improved from 99.1% to 99.9% based on linear and exponential functions. The PSV predictor based on the exponential model was evaluated with sixteen patient specific cases with a mean prediction error of 9.9% and standard deviation of 6.4%. Eleven out of sixteen cases (69%) in our current retrospective studies would have avoided CTA if the proposed predictor was used to screen out DUS measured PSV with prediction error greater than 15%. The predictor therefore has the potential to be used as a clinical tool to detect PSV more accurately post aortoiliac stenting and might reduce diagnostic errors and avoid unnecessary expense and risk from CTA follow-up imaging.
A 62-year-old woman was found incidentally to have a right carotid body tumour (CBT) during investigation for a transient ischemic attack. Computed tomography angiography confirmed a tumour measuring 1.5 ¥ 3 cm splaying the carotid bifurcation (see Fig. 1). The patient underwent preoperative embolization, with penetration of the tumour bed, 2 days before surgical resection (see Figs 2,3). After initial neck dissection, a lymph node was removed. Frozen section revealed the node to be benign. The tumour was successfully resected off the internal carotid artery (ICA) with ease. The patient made an uneventful recovery. Post-operative histology revealed the lymph node to contain metastatic deposits and as such the patient was confirmed as having metastatic malignant paraganglioma. Staging investigations showed no further evidence of metastatic disease. The patient underwent adjuvant radiotherapy. She experienced hoarse voice, dysphagia, radiation dermatitis, skin erosion and reduced hearing as a consequence.Our understanding of the behaviour and management of CBTs continues to grow, albeit at a slow rate given the relative uncommonness of these lesions. It is generally agreed upon that surgical treatment is the optimal management of these tumours in order to prevent long-term neurological sequelae that accompany tumour growth keeping in mind the not insignificant complications and difficulties encountered with these operations.The case described did not sustain residual post-operative neurological/nerve-related deficits; however, a multicentre review has shown significant post-operative morbidity of 35% and mortality of 1% -the risks being higher for larger tumours. 1 As a result, the concept of radiation therapy as an effective alternative to surgery has been explored and a series of 121 paragangliomas in a single institution managed with radiation therapy demonstrated a local control rate of 94% at 10 years. 2 Conclusive evidence required to publish a significant result is currently lacking because of the infrequency with which these lesions are encountered; however, it may not be entirely unreasonable to consider this option in elderly patients, those with significant co-morbidities and 'surgically unresectable' tumours. 3 Radiation is not without risks however, and this patient who received it post excision reported hoarse voice, dysphagia, radiation dermatitis, skin erosion and reduced hearing as a consequence.Preoperative embolization remains controversial, and despite the available literature a general consensus is not agreed upon. It remains a useful adjuvant option in large tumours (greater than or equal to 3 cm) and where the tumour is adherent and partially or completely surrounds the carotid vessels (as is the case with Shamblin classification I and II). 4-6 This procedure is not without risk, Fig. 1. Computed tomography angiogram demonstrating an enhancing mass lesion in the carotid bifurcation splaying the right external carotid artery and internal carotid artery. The lesion is 3 cm in craniocaudal dimen...
I would like to comment on just one of the many areas of concern in the recent article by Hernandez-Richter et al. 1 regarding the effectiveness of rifampin, triclosan and silver in the prevention of bacterial infection of vascular Dacron grafts.The InterGard w Silver prosthesis (InterVascular, La Ciotat, France) was autoclaved prior to use. Resterilisation by any method is contraindicated in the instructions for use of this commercially available product, as it is for other vascular grafts. The effects of steam on the silver deposition and on the collagen of the graft are unknown.The study design is, therefore, fundamentally flawed and consequently both the results and the conclusions are invalid.
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