Abdullah M. Al-Wahbi

Impact of a diabetic foot care education program on lower limb amputation rate

Background Diabetic foot complications are a leading cause of lower extremity amputation. With the increasing incidence of diabetes mellitus in the Arab world, specifically in the Kingdom of Saudi Arabia, the rate of amputation will rise significantly. A diabetic foot care program was implemented at King Abdulaziz Medical City in Riyadh, Saudi Arabia, in 2002. The program was directed at health care staff and patients to increase their awareness about diabetic foot care and prevention of complications. The purpose of this study was to perform a primary evaluation of the program’s impact on the rate of lower extremity amputation due to diabetic foot complications. Method This pilot study was the first analysis of the diabetic foot care program and examined two groups of participants for comparison, ie, a “before” group having had diabetic foot ulcers managed between 1983, when the hospital was first established, and 2002 when the program began and an “after group” having had foot ulcers managed between 2002 and 2004, in the program’s initial phase. A total of 41 charts were randomly chosen retrospectively. A data sheet containing age, gender, medical data, and the presentation, management, and outcome of diabetic foot cases was used for the analysis. Results The before group contained 20 patients (17 males) and the after group contained 21 patients (16 males). There was no difference between the two groups with regard to age and comorbidities. The rate of amputation was 70% in the before group and 61.9% in the after group. There was a decrease in the percentage of toe amputation in the after group and an increase in the percentage of below-knee amputation in the before group. However, these changes were not significant. Conclusion The program, although evaluated at an early stage, has increased the awareness of both patients and health care staff about the prevention and management of diabetic foot disease, and decreased the rate of lower extremity amputation. We believe that the statistical proof of its impact will be evident in the final evaluation.

Axillofemoral bypass with local anesthesia: a way forward to enable limb salvage in high-risk patients.

For an active, ambulant patient with critical, lower limb ischemia, amputation can lead to a poor quality of life. A small group of older people with critical limb ischemia are considered at high risk for revascularization under conventional anesthesia owing to their comorbid conditions. In these cases, when endovascular therapy is not an option, the decision to amputate or revascularize presents a dilemma, especially in ambulant patients. In this article, we present 2 cases in which the individuals had diabetic foot gangrene, rest pain, and multiple comorbidities, and were unfit to undergo conventional anesthesia. In addition, they had severe aortoiliac occlusive disease, which cannot be managed by endovascular methods. Both patients were living independently and were ambulant before their foot ulcer and ischemia. They underwent an axillofemoral bypass under local anesthesia. The postoperative course was uneventful. After a 3-year follow-up, both patients continue to be ambulant and have no complaints. With selective use of local anesthetic techniques, surgical teamwork to shorten the procedure time, and close meticulous postoperative care, an axillofemoral bypass can enable limb salvage for ambulant patients who are considered unfit for conventional anesthesia.

Leg ischemia post-varicocelectomy.

Varicocelectomy is the most commonly performed operation for the treatment of male infertility. Many surgical approaches are used as each of them has advantages over the other and is preferred by surgeons. Vascular injury has never been reported as a complication of varicocelectomy apart from testicular artery injury. We present a 36-year-old male who developed leg ischemia post-varicocelectomy due to common femoral artery injury. He was successfully treated by using a vein graft.

The Vascular Laboratory: A Proven Necessity for Optimal Vascular Disease Management but Rare in Developing Countries

It is well known that the noninvasive vascular laboratory is an important tool in the diagnosis and proper management of peripheral arterial disease; however, very few vascular centers in developing countries have this facility. This is mostly attributable to administrative obstacles, lack of interest from vascular surgeons, or insufficient resources. In this report, we present a brief overview of the importance of the vascular laboratory, our experience in the journey of establishing it, and try to give ideas to overcome obstacles.

Stent-grafts in the management of life-threatening hemorrhage following inadvertent femoral catheterization in high-risk patients: report of two cases and review of the literature

Bleeding related to inadvertent femoral catheter insertion is an infrequent but morbid complication. We report two cases of acute life-threatening bleeding after attempts at femoral vein catheterization. Both patients were morbidly obese, had multiple comorbidities, and were at high risk for surgical intervention. Aggressive resuscitation failed to stabilize the patients. Emergency digital subtraction angiography diagnosed the site of the femoral artery bleeding. In one patient, the site of injury was the right profunda femoris artery. Both bleeding sites were controlled successfully with endovascular covered stent placement, without complication. Although prior publications have reported the concept of endovascular repair in femoral artery injuries, to the best of the author’s knowledge, covering the profunda femoris artery with no complications has not been described previously. In critically ill patients with life-threatening hemorrhage following inadvertent femoral catheterization, management with endovascular covered stents is safe and effective.Bleeding related to inadvertent femoral catheter insertion is an infrequent but morbid complication. We report two cases of acute life-threatening bleeding after attempts at femoral vein catheterization. Both patients were morbidly obese, had multiple comorbidities, and were at high risk for surgical intervention. Aggressive resuscitation failed to stabilize the patients. Emergency digital subtraction angiography diagnosed the site of the femoral artery bleeding. In one patient, the site of injury was the right profunda femoris artery. Both bleeding sites were controlled successfully with endovascular covered stent placement, without complication. Although prior publications have reported the concept of endovascular repair in femoral artery injuries, to the best of the author’s knowledge, covering the profunda femoris artery with no complications has not been described previously. In critically ill patients with life-threatening hemorrhage following inadvertent femoral catheterization, management with endovascular covered stents is safe and effective.

Management of limb threatening ischaemia following bilateral Gelfoam embolisation of the internal iliac artery

lower morbidity as compared with primary PPH (King et al. 1989). Pelvic aneurysms are rare in young women. Most of these happen after gynaecological operations or caesarean sections. AV fistulas were thought to result from mass ligation of the artery or transfixing of a needle through the two vessels. The secondary aneurysm would be a pseudoaneurysm, which would not include all three layers of the arterial wall, whereas a true aneurysm would involve all three layers (Davidson et al. 1995). The diagnosis can be made with Doppler ultrasound but when small, and when rupture has occurred, visualisation may be difficult. Underlying arterial abnormality is often best demonstrated by angiography, and has the obvious added advantage of treatment by embolisation. When no bleeding vessel is identified, embolisation of both uterine arteries is necessary. Collateral arterial flow occurs a few hours after embolisation and prevents ischaemia (Hansch et al. 1999). Even though retention of products and endometritis are more frequent causes of secondary and delayed haemorrhage, angiographic exploration and subsequent treatment; a safe and effective treatment (Pelage et al. 1999), as in this case, led to a diagnosis which until recently would not have occurred and could have ended in a hysterectomy for recurrent secondary PPH.