Klaus Amendt

Readmissions of patients with diabetes mellitus and foot ulcers after infra-popliteal bypass surgery: attacking the problem by an integrated case management model

BACKGROUND Patients with neuroischemic diabetic foot syndrome (DFS) may need arterial revascularization, minor amputations, débridements as well as meticulous wound care. Unfortunately, postoperative outpatient care is frequently inadequate. This is especially true for Germany, where the in- and outpatient sectors are funded and managed separately, with poor communication between the two. Thus, many patients may be readmitted to the hospital following successful treatment and discharge. In an attempt to overcome these problems, we looked at whether an integrated case management (CM) system for outpatient care according to in-hospital standards might improve patients care and avoid readmissions. In addition we analyzed the length of hospital stay (LOS) as well as hospital costs. PATIENTS AND METHODS In this retrospective cohort study patients with DFS, bypass surgery and foot surgery after implementation of the CM (study group; n = 376) were compared with a matched historic control group (HCG; n = 190) including the flat rate revenues (G-DRG K01B). Following a standardized assessment, integrated trans-sectoral CM care was offered to 116 patients (CMP). RESULTS The proportion of patients who were readmitted to hospital was reduced in CMP compared to HCG (8.8 vs. 16.4 %; p < 0.01), with consequent reduction of case consolidations (9.7 % versus 17.8 %, p < 0.001). Although initially, the mean LOS was higher in the CMP patients, the reduction in readmissions meant that this integrated CM program improved the hospitals economic situation. CONCLUSIONS A hospital-based integrated CM system significantly reduces the hospital readmissions in patients with neuroischemic DFS following bypass surgery, with lower hospital costs.

Lower extremity vasculitis in giant cell arteritis: Important differential diagnosis in patients with lower limb claudication

Most patients with peripheral arterial disease suffer from arteriosclerosis, the prevalence of which increases with age. In some of these patients, however, the ischemic symptoms are not caused by stenotic arteriosclerosis, but by large vessel giant cell arteritis (LV-GCA), a disease also predominantly affecting patients of the older generation. Identifying large vessel vasculitis is a challenge for all physicians caring for patients with peripheral artery disease. The results of invasive treatment such as bypass surgery and angioplasty of inflammatory vascular lesions differ fundamentally from those of patients with atherosclerosis. Duplex ultrasound is a widely available diagnostic method for examining patients with lower limb claudication and pathological ankle-/toe- brachial index or pulse volume recording with or without exercise. Knowledge of characteristic sonographic findings suspicious about large vessel vasculitis is essential for a differential diagnosis of vasculitis versus atherosclerosis. In addition to clinical and laboratory findings, further imaging techniques, e.g. contrast-enhanced computed tomography, magnetic resonance imaging or a combination of positron emission tomography and computed tomography (PET-CT) can provide information on further vessel involvement and inflammatory activity. The present study focuses on diagnostic imaging of LV-GCA in patients presenting with claudication, illustrated by a series of cases.

Modernes Bildgebungsverfahren in der Diagnostik der Großgefäßvaskulitiden

ZusammenfassungDiese Übersichtsarbeit befasst sich mit der Diagnostik der beiden Großgefäßvaskulitiden Takayasu-Arteriitis und Riesenzellarteriitis mit Hauptaugenmerk auf das nuklearmedizinische Verfahren der Positronen-Emissions-Tomographie mit 18F-Fluordeoxyglykose (18F-FDG-PET) und die Kombination mit der Computertomographie (18F-FDG-PET/CT). Trotz der technischen Weiterentwicklungen spielt die klinische Diagnostik bzw. die Duplexsonographie bei der Abklärung der Großgefäßvaskulitiden weiterhin eine wesentliche Rolle. Allerdings kann die 18F-FDG-PET bzw. 18F-FDG-PET/CT für spezielle Fragestellungen, wie der Ausbreitungsdiagnostik und der Darstellung des Befallsmusters der Arteriitis, einen wichtigen Beitrag liefern. Dieser Artikel gibt einen Einblick in die aktuelle Wertigkeit und in potenzielle Einsatzmöglichkeiten der 18F-FDG-PET/CT.AbstractThis review article addresses the diagnostics of large vessel vasculitis (LVV), Takayasu vasculitis and giant cell vasculitis, with the focus on nuclear medicine techniques, namely positron emission tomography (PET) scans with 18F-fluorodeoxyglucose (18F-FDG-PET) and in combination with computed tomography (18F-FDG-PET/CT). Clinical diagnostics and duplex ultrasound still play a central role in the diagnostic workup of LVV, notwithstanding the technical improvements of these nuclear medicine techniques over the last years. The 18F-FDG-PET and 18F-FDG-PET/CT methods offer important clinical value for specific questions, such as disease dissemination or the pattern of dissemination of LVV. This article summarizes the current value and field of potential applications of 18F-FDG-PET/CT.

First clinical experience with the Multi-LOC multiple stent delivery system for focal stenting in long femoro-popliteal lesions

Background: The purpose of this observational study is to report the six-month clinical outcomes with a new multiple stent delivery system in patients with femoro-popliteal lesions. Patients and methods: The LOCOMOTIVE study is an observational multicentre study with a primary endpoint target lesion revascularization (TLR) rate at six months. Femoro-popliteal lesions were prepared with uncoated and/or paclitaxel-coated peripheral balloon catheters. When flow limiting dissections, elastic recoil or recoil due to calcification required stenting, up to six short stents per delivery device, each 13 mm in length, were implanted. Sonographic follow-ups and clinical assessments were scheduled at six months. Results: For this first analysis, a total of 75 patients 72.9 ± 9.2 years of age were enrolled. The majority of the 176 individually treated lesions were in the superficial femoral artery (76.2 %, 134/176) whereas the rate of TASC C/D amounted to 51.1 % (90/176). The total lesion length was 14.5 ± 9.0 cm with reference vessel diameters of 5.6 ± 0.7 mm. Overall 47 ± 18 % of lesion lengths could be saved from stenting. At six months, the patency was 90.7 % (68/75) and all-cause TLR rates were 5.3 % (4/75) in the overall cohort. Conclusions: The first clinical experience at six months suggests that the MSDS strategy was safe and effective to treat femoro-popliteal lesions of considerable length (14.5 ± 9.0 cm). Almost half of the lesion length could be saved from stenting while patency was high and TLR rates were acceptably low.

Multiple stent delivery system Multi-LOC, a new technology for spot-stenting of the femoropopliteal artery – proof of concept study in a preclinical large animal model

BACKGROUND A new stent system was studied in a porcine model to evaluate its feasibility for spot-stenting of the femoropopliteal artery. MATERIALS AND METHODS In a preliminary study in a single pig, handling and mechanical features of the novel multiple stent delivery system were tested. The Multi-LOC system demonstrated great feasibility regarding its pushability, trackability, and crossability. Excellent visibility of the individual stents allowed exact anatomically controlled implantation. In our main study, four to five short Multi-LOC stents (13 mm long) were implanted into the femoropopliteal arteries of six domestic pigs and long (60 to 100 mm) self-expandable nitinol stents were implanted into the same target vessel contralaterally to allow for intraindividual comparison. After four weeks survival under dual antiplatelet treatment, control angiography was performed. The animals were euthanized, stented vessels were explanted, and histologic sections were examined for the presence of neointimal formation. RESULTS Multi-LOC stents demonstrated no occlusion of the femoropopliteal axis (0 vs. 1 occlusion distal to a control stent), no stent fractures (0 out of 26 vs. 2 out of 6 control stents), and lower percentage diameter stenosis (0.564 ± 0.056 vs. 0.712 ± 0.089; p = 0.008) and length of stenosis (19.715 ± 5.225 vs. 39.397 ± 11.182; p = 0.007) compared to a standard control stent, which was similar in total length to the multiple stented artery segment. Histological examination confirmed myointimal hyperplasia underlying in-stent stenosis. CONCLUSIONS The multiple stent delivery system was studied in a porcine model, which demonstrated its feasibility. Preclinical experience revealed favourable results concerning stent fracture, restenosis, and patency of spot-stented femoropopliteal arteries.