Sheila N. Blumberg

The role of stem cells in the treatment of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a significant and rapidly growing complication of diabetes and its effects on wound healing. Over half of diabetic patients who develop a single ulcer will subsequently develop another ulcer of which the majority will become chronic non-healing ulcers. One-third will progress to lower extremity amputation. Over the past decade, the outcomes for patients with DFUs ulcers have not improved, despite advances in wound care. Successful treatment of diabetic foot ulcers is hindered by the lack of targeted therapy that hones in on the healing processes dysregulated by diabetes. Stem cells are a promising treatment for DFUs as they are capable of targeting, as well as bypassing, the underlying abnormal healing mechanisms and deranged cell signaling in diabetic wounds and promote healing. This review will focus on existing stem cell technologies and their application in the treatment of DFUs.

Mesenchymal stem cell therapy and delivery systems in nonhealing wounds.

PURPOSE: To enhance the learners competence with knowledge of mesenchymal stem cell (MSC) therapy and delivery systems in nonhealing wounds. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: Apply knowledge of the physiology of wound healing to the use of MSCs to improve the wound healing process. Analyze research investigating the use of MSC with a variety of delivery systems for enhanced wound healing. OBJECTIVE: The objective of the study was to inform wound care practitioners of mesenchymal stem cell application for nonhealing wounds. Recent advances in delivery systems are also discussed in order to highlight potential improvements toward clinical application of stem cell therapy for chronic wounds. DATA SOURCES: MEDLINE and PubMed Central were searched for scientific studies regarding the use of mesenchymal stem cells and delivery systems in wound healing. STUDY SELECTION: Preclinical studies using stem cells as therapeutic modality for chronic wounds were selected for this review. DATA EXTRACTION: Information on study design, sample size and characteristics, stem cell source, type of delivery systems, and rate and time of wound closure was abstracted. DATA SYNTHESIS: Application of mesenchymal stem cells improved wound healing in experimental and clinical settings. Advances in stem cell therapy and delivery vehicles offer promising alternatives to current limited therapeutic modalities for chronic wounds. CONCLUSIONS: Stem cell therapy has recently emerged as a promising therapeutic strategy for nonhealing wounds. Further research is needed to evaluate the relationship between the various delivery systems and stem cells in order to maximize their therapeutic effects. Development of novel delivery vehicles for stem cells can open new opportunities for more effective cell therapy of chronic wounds.

A multidisciplinary team approach to hydroxyurea-associated chronic wound with squamous cell carcinoma

Hydroxyurea (HU) has been shown to induce a variety of cutaneous adverse reactions, including severe leg ulcers. This report shows a successful treatment of a HU‐induced chronic wound associated with squamous cell carcinomas (SCC). A 62‐year‐old patient affected with polycythemia vera and treated with HU for 10 years, presented with a non healing ulcer on a left heel. The patient gave a history of suffering from the wound for over 2 years. Biopsy showed evidence of invasive SCC. The patient underwent Mohs surgery and a greater saphenous vein ablation for polycythemia vera‐associated vascular complications. The wound consistently decreased in size following successive debridements and coverage with human skin equivalent. The wound healed completely after a 6‐month period. A multidisciplinary team approach to the treatment proved to be effective resulting in healing of this multifactorial chronic ulcer.

Gender Differences in Aortic Neck Morphology in Patients with Abdominal Aortic Aneurysms Undergoing Elective Endovascular Aneurysm Repair

BACKGROUND Previous studies have demonstrated that women tend to have adverse aortic neck morphology leading to exclusion of some women from undergoing endovascular aneurysm repair (EVAR). The objective of this study is to investigate differences in aortic neck morphology in men versus women, changes in the neck morphology and sac behavior after EVAR, and investigate how these features may influence outcomes. METHODS We conducted a retrospective review of elective EVARs (2004-2013). We excluded patients who underwent elective EVAR with no postoperative imaging available and those patients with fenestrated repairs. Using TeraRecon and volumetric analysis, several features were investigated. These included percent thrombus, shape, length, angulation of the neck, and changes in neck and abdominal aortic aneurysm diameter. RESULTS A total of 146 patients were found to meet inclusion criteria (115 men and 31 women) with similar baseline characteristics. Neck angulation was greater in women (23.9° vs. 13.5°; P < 0.028). The percent thrombus in women was higher than men (35.4% vs. 31%; P < 0.02). Abdominal aneurysms were smaller in women at 1 year (4.2 cm vs. 5.1 cm; P < 0.002), and secondary interventions were higher in men (11.3% vs. 0%; P < 0.05). Other features such as neck shape, changes in neck diameter, neck length, and percent oversizing of graft where not statistically different between genders. CONCLUSIONS Gender differences in neck characteristics and changes in neck morphology do not appear to adversely affect EVAR outcomes. Longer follow-up is necessary to further assess whether these findings are clinically durable.

Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration hospital (在公立、私立以及退伍军人管理局医院中的糖尿病足溃疡的最初表现与治疗结果的差异)

Disparities in diabetic foot ulcer (DFU) treatment outcomes are well described, although few studies identify risk factors contributing to disparate healing and amputation rates. In a unique academic center serving urban public, private, and veteran patients, we investigated amputation and healing rates and specific risk factors for disparate treatment outcomes.

Pneumatic Compression Improves Quality of Life in Patients with Lower-Extremity Lymphedema.

BACKGROUND Lymphedema is an incurable and disfiguring disease secondary to excessive fluid and protein in the interstitium as a result of lymphatic obstruction. Pneumatic compression (PC) offers a novel modality for treatment of lymphatic obstruction through targeting lymphatic beds and mimicking a functional drainage system. The objective of this study is to demonstrate improved quality of life in patients with lower-extremity lymphedema. METHODS Consecutive patients presenting to a single institution for treatment of lymphedema were all treated with PC for at least 3 months. All patients underwent a pre- and post-PC assessment of episodes of cellulitis, number of ulcers, and venous insufficiency. Post-PC symptom questionnaires were administered. Symptom improvement was the primary outcome for analysis. RESULTS A total of 100 patients met inclusion criteria. At presentation, 70% were female with a mean age of 57.5 years. Secondary lymphedema was present in 78%. Mean length of PC use was 12.7 months with a mean of 5.3 treatments per week. Ankle and calf limb girth decreased after PC use, (28.3 vs. 27.5 cm, P = 0.01) and (44.7 vs. 43.8 cm, P = 0.018), respectively. The number of episodes of cellulitis and ulcers pre- and post-PC decreased from mean of 0.26-0.05 episodes (P = 0.002) and 0.12-0.02 ulcers (P = 0.007), respectively. Fourteen percent had concomitant superficial venous insufficiency, all of whom underwent venous ablation. Overall 100% of patients reported symptomatic improvement post-PC with 54% greatly improved. 90% would recommend the treatment to others. CONCLUSIONS PC improves symptom relief and reduces episodes of cellulitis and ulceration in lower-extremity lymphedema. It is well tolerated by patients and should be recommended as an adjunct to standard lymphedema therapy. Screening for venous insufficiency is recommended.

Endovascular Treatment of Spontaneous Renal Artery Dissection After Failure of Medical Management

Spontaneous renal artery dissection (SRAD) is a rare disease with approximately 200 cases reported in the literature. The severity of renal compromise, the anatomic location of the dissection, and the presence of uncontrollable hypertension are used to guide the initial management of SRAD. However, there are no reported guidelines for managing the progression of SRAD after acute failure of medical management. In this case, a 40-year-old man with a recently diagnosed SRAD was managed appropriately with therapeutic anticoagulation, yet presented with progression of his dissection and a new acute renal infarct. A covered endovascular stent was used to successfully control dissection progression and prevent further renal compromise.

Percutaneous fenestrated endovascular aortic graft treatment of aortocaval fistula with aortic pseudoaneurysms secondary to penetrating trauma

&NA; Aortocaval fistula (ACF) is a lethal complication of aortic aneurysmal disease. Traditional treatment of ACF involves open surgical approaches to fistula ligation and repair of the great vessels, with a high mortality secondary to bleeding and cardiac compromise. We present the case of a 28‐year‐old man with a chronic ACF with concomitant aortic pseudoaneurysms secondary to penetrating trauma treated with a fenestrated endograft.

Clinical correlation of the area of inferior vena cava, iliac and femoral veins for stent use

Objective The purpose of the study is to evaluate normal anatomical areas of infrarenal inferior vena cava, common iliac, external iliac and common femoral veins by intravascular ultrasound with the goal of assisting the development of venous-specific stents in the treatment of iliac vein stenosis. Method From February 2012 to December 2013, 656 office-based venograms were performed in our facility. Among them, 576 were stented and 80 were not. The measurements of veins were done intraoperatively using an intravascular ultrasound catheter to record areas of the inferior vena cava, proximal, middle and distal segments of common iliac vein, external iliac vein and common femoral vein. The data were compared between non-diseased segments of patients who were stented and those not stented. The stented diseased segments were excluded. Results The mean patient age was 67.33 years (range 22–96, SD ±13.99). Our data included 218 males, 438 females and 324 right lower extremities and 332 left lower extremities. The presenting symptoms of these patients based on CEAP were C1(0), C2 (185), C3(233), C4(107), C5(89) and C6(42). No correlation was found between area of veins and age, gender, laterality and CEAP score (P > .13). Comparison of the areas of non-diseased iliac vein segments between patients not stented and patients who underwent stenting showed a significant difference, with larger areas in non-stented patients in the distal common iliac vein (P = .039) and inferior vena cava (P = .012). Younger age (P = .03) and male gender (P < .0001) were associated with increased area of iliac vein segments. Conclusion Utilizing the intravascular ultrasound-guided technique, we were able to define normal anatomical areas of non-diseased inferior vena cava, iliac and femoral veins, which could be employed to guide the development of appropriate-sized stents and other tools needed for the treatment of venous insufficiency. There is specific variability in areas of normal vein segments with age and gender with/without stents.

IP265 Underexpansion of Iliac Vein Stents in the Treatment of Venous Insufficiency

hemodynamic changes in the operative extremity. This study for the first time investigated changes in calf muscle pump function after TKA. The study hypothesis stated improvement in calf muscle pump function after TKA would improve venous health and quality of life for patients. Methods: This prospective pilot study compared preoperative and postoperative measurements and unilateral patient control in patients undergoing TKA with postoperative follow-up at 1, 2, and 3 months. Clinicians from the Divisions of Vascular Surgery and Orthopedics conducted the study. Demographics including smoking status and CEAP classification were obtained (Table I). Quality of life was assessed using the Chronic Venous Insufficiency Questionnaire. Preoperative and postoperative Venous Clinical Severity Score, body mass index, leg measurements, and assessment of calf muscle pump function (venous volume, ejection volume, and ejection fraction) using air plethysmography were measured (Table II). Mean and standard deviation were calculated, with descriptive variables compared using Wilcoxon signed rank test. Probability of P < .05 was considered statistically significant Results: A total of 19 patients (68.4% female), mean age 64.6 6 5.6, were evaluated between June 2013 and June 2015. Quality of life was shown to improve postoperatively with significant reductions in Chronic Venous Insufficiency Questionnaire scores (62.7 vs 48.3; P 1⁄4 .002). Postoperative venous volume (78.5 vs 103.3; P 1⁄4 .025), ejection volume (27 vs 102; P 1⁄4 .023), and ejection fraction (42.5 vs 74.4; P 1⁄4 .0017) were all significantly increased, indicating an improvement of calf muscle pump function. Also, body mass index decreased significantly postoperatively (32.3 vs 31.5; P 1⁄4 .02). Conclusions: Our pilot study indicates, for the first time, a significant improvement in calf muscle pump function, quality of life, and body mass index postoperatively in patients undergoing TKA. This may be attributable to increased range of motion and ambulation, although more investigation is required.