A 58-year-old male patient with severe claudication due to thrombosis of the left ilio-femoro-popliteal artery aneurysm. He also had a venous stasis ulcer with a history of multiple embolotherapy of arteriovenous malformation. Duplex sonography revealed reflux and varicose veins of the left great saphenous vein (GSV). A sequential bypass surgery was performed that consisted of excision of the left external iliac and common femoral artery aneurysm, external iliac to deep femoral interposition with an expanded polytetrafluoroethylene graft, and femoro-posterior tibial artery bypass with the reversed left GSV. Symptoms of claudication were alleviated and the chronic ulcer was healed in time. To our knowledge, this is the first report of successful bypass in a patient with arterial aneurysm, arteriovenous malformation, and venous insufficiency that can be diagnosed as an atypical case of Parkes Weber syndrome. Long-term follow-up is needed to define the fate of aneurysms and varicose vein graft.
Aneurysm ; Arteries ; Arteriovenous Fistula ; Arteriovenous Malformations ; Embolization, Therapeutic ; Femoral Artery ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Polytetrafluoroethylene ; Popliteal Artery ; Saphenous Vein ; Sturge-Weber Syndrome ; Thrombosis ; Tibial Arteries ; Transplants ; Ulcer ; Varicose Ulcer ; Varicose Veins ; Venous Insufficiency

BACKGROUND/AIMS: Various clinical scoring systems, including the Glasgow-Blatchford score (GBS), Rockall risk score (RS), and AIMS65 score (AIMS65), have been validated to predict the clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). We compared the performance of these three scoring systems in predicting clinical outcomes in patients with UGIB in Korea. METHODS: We retrospectively evaluated 286 patients with UGIB who visited emergency department. The primary outcome was the need for clinical intervention (endoscopic, radiologic, or surgical) and blood transfusion. RESULTS: The causes of UGIB were esophageal/gastric varices in 64 patients, peptic ulcer in 168, Mallory-Weiss tear in 32, malignancy of UGI tract in eight, and unknown in 14. One hundred seventy-four (61%) patients required blood transfusion, 166 (58%) required endoscopic intervention, and 10 (3.5%) required surgical intervention. The GBS outperformed the RS and AIMS65 in predicting the need for endoscopic intervention. CONCLUSIONS: The GBS and RS were more accurate than AIMS65 in predicting the need for clinical interventions and transfusion patients with UGIB, regardless of variceal or nonvariceal bleeding. The AIMS65 may not be optimal for predicting clinical outcomes of UGIB in Korea.
Blood Transfusion ; Emergency Service, Hospital ; Gastrointestinal Hemorrhage ; Hemorrhage* ; Humans ; Korea ; Mallory-Weiss Syndrome ; Mortality ; Peptic Ulcer ; Retrospective Studies ; Risk Assessment ; Varicose Veins

Acupuncture Therapy ; Humans ; Lower Extremity ; blood supply ; Male ; Middle Aged ; Varicose Ulcer ; therapy

PURPOSE: The aims of our study were to evaluate the blood urea nitrogen to creatinine ratio (BUN/Cr ratio) for distinguishing between an upper and lower gastrointestinal bleeding (GIB), and differentiating between the two most common causes of upper gastrointestinal bleeding (UGIB) presenting with melena in children. METHODS: Retrospective data of patients with GIB presenting with melena were analyzed. The data from 60 cases were reviewed including demographics, laboratory findings, diagnostic modalities and results, treatments, and transfusions. RESULTS: Among the 60 cases, UGIB and lower gastrointestinal bleeding (LGIB) were found in 35 cases (58.3%) and 14 cases (23.3%), respectively. The two common causes of UGIB were varices (37.1%), and peptic ulcer diseases (PUD) (31.4%). The BUN/Cr ratio of 30 or greater was higher in UGIB than LGIB (odds ratio [OR], 6.9; 95% confidence interval [95% CI], 1.3-37.2). In UGIB, the BUN/Cr ratio of the varices group was higher than that of the PUD group (p=0.015). The OR for the BUN/Cr ratio appeared as 1.2 per unit increase in the varices group than the PUD group (95% CI, 1.03-1.3). There was no difference between the PUD group and Meckel's diverticulum group. CONCLUSION: The BUN/Cr ratio was not uneven in differentiating UGIB from LGIB of children with melena in our study. This suggests that BUN/Cr ratio should be interpreted carefully.
Blood Urea Nitrogen ; Child* ; Creatinine ; Demography ; Hemorrhage* ; Humans ; Meckel Diverticulum ; Melena* ; Peptic Ulcer ; Retrospective Studies ; Urea* ; Varicose Veins

Squamous cell carcinoma commonly originates from recalcitrant wound sites, including burn scars, pressure sores, stasis ulcers, osteomyelitis, and sites of frostbite. A 62-year-old male was referred to the dermatology department for skin necrosis of his right great toe and walking difficulty. He had a history of smoking, drinking alcohol, and frostbite of his right great toe 9 years prior, which deteriorated into osteomyelitis due to poor care. Although a skin biopsy was recommended before amputation, the two procedures were performed simultaneously due to a lack of toe function due to severe osteolysis. Biopsy of the amputated toe tip showed many lobules consisting of atypical keratinocytes with hyperchromatic nuclei, and severe dermal pleomorphism. After evaluation for distant metastasis, including a (99m) Tc-MDP bone scan, 18F-FDG positron emission tomography scan, computed tomography, and ultrasound, no metastasis was detected.
Amputation ; Biopsy ; Burns ; Carcinoma, Squamous Cell* ; Cicatrix ; Dermatology ; Drinking ; Fluorodeoxyglucose F18 ; Frostbite ; Humans ; Keratinocytes ; Male ; Middle Aged ; Necrosis ; Neoplasm Metastasis ; Osteolysis ; Osteomyelitis* ; Positron-Emission Tomography ; Pressure Ulcer ; Skin ; Smoke ; Smoking ; Toes ; Ultrasonography ; Varicose Ulcer ; Walking ; Wounds and Injuries

BACKGROUNDConventional high ligation and stripping of the great saphenous vein (GSV) has a good curative effect but is highly traumatic with a considerable relapse rate. Subfascial endoscopic perforator surgery (SEPS) plus endovenous laser treatment (EVLT) could be applied as individual therapy. This study aimed to evaluate the feasibility of performing combined SEPS and EVLT without impacting GSV in the management of valvular insufficiency of the lower-limb venous perforators.

METHODSPlacement of lower-limb venous perforator insufficiency was marked by ascending phlebography in 83 affected limbs from September 2010 to June 2011. After randomization, SEPS was performed on 41 limbs to address the insufficiency of the venous perforators under the deep fascia, in combination with EVLT to close the superficial varicose veins without impacting the GSV. The remaining 42 limbs were treated using traditional GSV phlebectomy as controls.

RESULTSPostoperatively, all varicose veins were resolved, with lightening of the pigmentation and healing of the ulcer. Within a follow-up period of 5 - 11 months, no symptoms had recurred. Compared with the control group, the operation time, the number of incisions sutured, and the in-hospital time decreased on average by 1.5 hours, 4.7, and 6.8 days, respectively (P < 0.01 in all cases).

CONCLUSIONCombined SEPS and EVLT for treatment of valvular insufficiency of the lower-limb venous perforators offer the advantages of microtrauma and rapid cure.

Adult ; Aged ; Endovascular Procedures ; methods ; Female ; Humans ; Male ; Middle Aged ; Saphenous Vein ; surgery ; Varicose Ulcer ; surgery ; Varicose Veins ; surgery ; Vascular Surgical Procedures ; methods

BACKGROUND/AIMS: Matrix metalloproteinases (MMP)-2 and -9 can degrade essential components of vascular integrity. The aim of this study was to investigate the association between those MMPs and variceal bleeding (VB). METHODS: Fifteen controls, 12 patients with acute ulcer bleeding (UB) group, 37 patients with varix (V group), and 35 patients with acute VB group were enrolled. Serum was obtained to measure MMP-2 and -9 activity by zymogram protease assays. RESULTS: The activity levels of these compounds were compared with the controls' median value. The median MMP-9 activity was 1.0 in controls, 1.05 in the UB group, 0.43 in the V group, and 0.96 in the VB group. The level of MMP-9 activity was higher in the VB group than in the V group (p<0.001). In the VB group, there was a signifi cant decrease in MMP-9 activity over time after bleeding (p<0.001). The median MMP-2 activity level was 1.0 in controls, 1.01 in the UB group, 1.50 in the V group, and 1.55 in the VB group. The level of MMP-2 activity was similar in the VB and V groups. CONCLUSIONS: The level of MMP-9 activity increased in association with VB. The role of MMP-9 in the pathogenesis of VB should be verified.
Esophageal and Gastric Varices ; Hemorrhage ; Humans ; Matrix Metalloproteinase 2 ; Matrix Metalloproteinase 9 ; Matrix Metalloproteinases ; Ulcer ; Varicose Veins

OBJECTIVETo explore the potential causes and the optimal treatments of recurrent venous ulceration of lower limbs after initial operation.

METHODSData of patients admitted between January 2000 and June 2010 for recurrent ulceration in lower limbs after previous operation were retrospectively analyzed. Altogether 81 limbs in 73 patients were recruited. There were 55 male patients (60 limbs) and 18 female patients (21 limbs). The average age was 52.6 years (ranging from 31 to 73 years). All the patients had received at least one surgery procedures before recurrence. The average time between ulceration recurrence and the last operation was 10.6 months (ranging from 5 to 37 months). Average diameter of ulcers was 3.7 cm (ranging from 1.3 to 6.5 cm). Color duplex sonography before re-treatment revealed incompetent calf perforators in 57 limbs (70.4%), primary deep vein insufficiency in 38 limbs (46.9%), post-DVT syndrome in 16 limbs (19.8%), reflux of accessory saphenous veins in 11 limbs (13.6%) and residual/re-opened great saphenous vein in 8 limbs (9.9%). Managements including stripping of great saphenous vein, ligation around the ulcer, percutanous ligation of varicose veins, valvoplasty, and adjuvant compressive therapy were adopted according to different venous abnormality.

RESULTSAll the patients were followed. All the ulcers healed and hemodynamic indexes were greatly improved 6 months after re-operation. Only 3 limbs (3.7%) suffered again from recurrence 1 year after re-operation.

CONCLUSIONSIncompetent perforators in calf, primary or secondary deep vein insufficiency and incorrectly treated saphenous veins are main causes for recurrent venous ulceration in our series. Management of residual vein abnormalities can still achieve satisfying clinical outcome.

Adult ; Aged ; Female ; Humans ; Leg ; blood supply ; Male ; Middle Aged ; Recurrence ; Retrospective Studies ; Varicose Ulcer ; etiology ; surgery ; Varicose Veins ; etiology ; surgery

PURPOSE: Venous stasis ulcer is the most severe form of chronic venous insufficiency and this commonly appears in the lower limb. Pharmacological therapy, reconstruction of the venous system, surgical management, cellular therapy and compression therapy are known as the treatments of venous stasis ulcer, but relapses are common, which make it a typical chronic wound. We report here on a case of recurrent venous stasis ulcer that healed with compression therapy without any other treatment. METHODS: A 35-year-old man with a 13 years history of venous stasis had developed an ulcer on the distal third portion of the lower left limb which was developed 12-year before enrollment in this study. He had been treated with vacuum assist closure, 2 times of cell therapy and 3 times of skin graft for 8 years, but the lesion recurred. From November, 2008 compression therapy was done with the 3M Coban(TM) 2 Layer Compression System(3M, St. Paul, USA). The ulcer at that time was oval shaped and 3x4cm in size. A comfort layer bandage was applied from the proximal phalanx of the great toe to the knee. A compression layer bandage was applied on the previous layer with it being overlapped one half the width of the comfort layer bandage. The dressing was changed every 4 days and the change was recorded with photography. RESULTS: A total of 12 Coban(TM) 2 Layer Compression Systems were used. The size of the ulcer decreased to 2.5x2.5cm in one month, to 2x2cm in 2 months, it was 1x1.8cm in size at 3 months and it completely healed in 4 months. CONCLUSION: The venous stasis ulcer was completely healed using the 3M Coban(TM) 2 Layer Compression System. This method was easy to apply, made the patient comfortable and it provided an excellent compression effect. As in the previous studies, this compression therapy has been proven to play an important role for the treatment and prevention of venous stasis ulcer.
Adult ; Bandages ; Extremities ; Humans ; Knee ; Lower Extremity ; Recurrence ; Skin ; Tissue Therapy ; Toes ; Transplants ; Ulcer ; Vacuum ; Varicose Ulcer ; Venous Insufficiency

A twenty six year old man was admitted to our clinic for bleeding from a venous ulcer of the left leg. His left femoral vein had been ligated for bleeding control after a traffic accident that happened when he was 5 years old. He had a varicose vein, stasis dermatitis, and a venous ulcer on his left leg. To shunt left femoral venous return to the right femoral vein, we did a crossover bypass with arteriovenous fistula using the right greater saphenous vein. To get good patency of the arteriovenous fistula, the bypass graft was closed 6 weeks after the initial operation. He maintained his left leg circumference relatively well for 6 months after the operation. We report the case of a patient who had a vein crossover bypass for a chronic femoral vein ligation.
Accidents, Traffic ; Arteriovenous Fistula ; Dermatitis ; Femoral Vein ; Hemorrhage ; Humans ; Leg ; Ligation ; Saphenous Vein ; Transplants ; Varicose Ulcer ; Varicose Veins ; Veins