Search

Objectives: To determine the prevalence of vasculopathic diabetic foot and the associated factors in a Saudi tertiary center. Methods: This retrospective chart review included adult patients (≥18 years) diagnosed with diabetic foot between May 2015 and July 2019 in King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. Based on clinical presentation and laboratory results, the patients were categorized into 2 groups namely, “vascular induced diabetic foot group” and “non-vascular induced diabetic foot group”. Results: A total of 404 diabetic patients were enrolled in the study. The mean age of the patients was 62.03±12.30 years; 61.9% were males. Most of the diabetic foot cases had a non-vascular etiology (n=327, 80.9%), while 77 cases (19.1%) were due to vasculopathy. Patient in the vascular group had a significantly higher incidence of coronary artery disease (32.5% versus 14.4%; p greater than 0.001), and a higher incidence of peripheral artery disease (PAD) in the unaffected limb (22.1% versus 2.1%; p less than 0.001). Conclusion: Most cases of diabetic foot were due to non-vascular causes. Old age, history of coronary artery disease, or PAD in the unaffected limb were factors that were significantly associated with diabetic foot due to arterial disease. Saudi Med J 2021; Vol. 42 (1): 49-55 doi: 10.15537/smj.2021.1.25640 How to cite this article: Altoijry A, AlGhofili H, Alanazi SN, AlHindawi DA, AlAkeel NS, Julaidan BS, AlHamzah M, Altuwaijri T. Diabetic foot and peripheral arterial disease. Single centre experience. Saudi Med J. 2021 Jan;42(1):49-55. doi: 10.15537/smj.2021.1.25640. PMID: 33399171.

To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS).This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months).A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases.Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

Background: The purpose of this study was to assess the risk of venous thromboembolism (VTE) and the potential need for thromboprophylaxis in patients with tuberculosis (TB). Methods: A total of 103 patients who underwent treatment for TB at the King Khalid University Hospital in Riyadh between February 2015 to May 2018, the percentage of patients diagnosed with TB who developed VTE was assessed. This was a retrospective cohort study conducted at King Khalid University Hospital in Riyadh. Fisher's exact test was used to analyze the categorical variables.P < 0.05 was considered statistically significant. Results: Our data showed the prevalence of VTE in TB patients to be 2.93% (3/103). VTE occurred irrespective of the type of TB (pulmonary and/or extrapulmonary). All TB patients with VTE showed no significant association with factors such as human immunodeficiency virus coinfection, malignancy, and multidrug-resistant TB. Conclusion: Our study showed that TB patients in Saudi Arabia may be at a higher risk for developing VTE and should be carefully monitored as potential candidates for additional thromboprophylaxis; further studies are recommended to establish more reliable assessment and recommendations.

Background: Despite the growing importance and increased use of laparoscopy for gallbladder diseases in Saudi Arabia, several factors reportedly result in conversion to open surgery. This leads to increased operative time and increased hospital resource utilization, and, importantly, it impacts patient welfare. Although laparoscopic cholecystectomy and its conversion rates have been investigated in Saudi Arabia, there is little information on the factors associated with this conversion. Therefore, we analyzed the prevalence and factors associated with the conversion from laparoscopic to open cholecystectomy. Materials and methods: This was a quantitative, retrospective, observational, cross-sectional study. We reviewed the health care records of all patients who underwent laparoscopic cholecystectomy during the study period (January 2014–December 2015). We analyzed patient demographics, preoperative factors, ultrasound findings, and intraoperative factors associated with higher conversion rates. We calculated means, SDs, and medians for numerical variables and percentages and frequencies for nominal variables. The χ2 and two-tailed t tests were used to compare the categorical and continuous variables, respectively, between patients who underwent laparoscopic cholecystectomy and those who underwent conversion to open cholecystectomy to analyze their relationship with the possibility of conversion. Statistical significance was considered at P < 0.05. Results: Age > 40 years, diabetes, history of admission for gallstones, and increased total bilirubin, direct bilirubin, and alkaline phosphatase levels were the preoperative factors and adhesions, bleeding, and stone spillage were the intraoperative factors associated with conversion. Conclusion: Recognizing the factors for conversion would improve treatment planning and help predict when conversion may be necessary.

Background The emergency surgery score (ESS) has emerged as a tool to predict outcomes in emergency surgery (EGS) patients. Our study examines the ability of ESS to predict outcomes in EGS admissions. Methods All EGS admissions to King Saud University Medical City (KSUMC) from January 2017 to October 2019 were included. ESS was calculated for each patient. Correlations between ESS and 30-day mortality and complications were evaluated. Results 1607 patients were included. 30-day mortality rate was 2.2% while complication rate was 18.7%. Mortality increased as ESS increased, from 0.3% for ESS≤2, to 30.1% for ESS >10, with a c-statistic of 0.88. Complication rates were 2.2%, 40%, and 100% at ESS of 0, 6, and 15, respectively, with a c-statistic of 0.82. Conclusions ESS accurately predicted outcomes at our tertiary center. ESS could be useful in identifying high risk EGS admissions and in benchmarking quality of care across Saudi institutions.

Renal artery aneurysm (RAA) is defined as a localized saccular or fusiform dilation of the renal vasculature that exceeds 50% of the adjacent artery diameter. RAAs are rare in the general population and account for

Lower limb varicose veins are a common vascular disorder producing pain and disability when truncal vein reflux is present. Endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a safe and effective method for treating this condition. An unintended complication of this procedure is endothermal heat-induced thrombosis (EHIT) of common femoral vein. A retrospective outcomes analysis of patients who underwent EVLA of the GSV at King Khalid University Hospital from June 2006 to November 2018 was conducted to identify the risks factors and incidence of EHIT. Patients were assessed by clinical examination and duplex ultrasound imaging after the EVLA, and patient demographic characteristics and procedural factors predictive of EHIT were determined. Following EVLA, 11,070 duplex ultrasound examinations were performed for 1,230 limbs, and EHIT was detected in 65 (5.3%) limbs in 60 (6.8%) patients. Essentially all EHIT cases were detected in the first week (n = 63; 96.9%) and clot regression occurred over a period of 1-4 weeks. There were no significant differences in patient demographic characteristics or procedural factors between the EHIT and non-EHIT groups, except for the percentage of women (86% v 73%; P = .02), maximum GSV diameter (6.7 ± 2.7 mm v 6.0 ± 2.1 mm; P = .04), and percentage of patients with a competent saphenofemoral junction (41% v 37%; P .001). EVLA is a safe treatment for great saphenous vein reflux, but EHIT can occur and was associated with female sex, large maximum GSV diameter, and competent saphenofemoral junction. Venous duplex imaging after EVLA is recommended because EHIT is asymptomatic in most patients.

Background Arterial pseudoaneurysms are a well-known complication resulting from procedures requiring arterial wall puncture. Previously, surgical repair was the definitive treatment option for arterial pseudoaneurysms despite being relatively invasive and time-consuming. Ultrasound-guided thrombin injection (UGTI) has become the standard of care since its initial description back in 1997. We aimed to evaluate the safety and efficacy of UGTI for the treatment of arterial pseudoaneurysms at the King Khalid University Hospital Vascular Lab. Methods A retrospective analysis of prospectively maintained data was conducted on all patients diagnosed with arterial pseudoaneurysms by Doppler ultrasound between 2006 and 2019. Patients with large arterial pseudoaneurysms (>1.5 cm) qualified for thrombin injections. Individuals with a known hypersensitive to thrombin were excluded. All included patients were treated with UGTI until resolution and were followed at postoperative days 7 and 30. Results In all, 35 patients qualified for thrombin injections. The mean age of the included patient population was 56.5 (range, 24-81) years. The majority of them were hypertensive (N.=26, 74.3%), and a quarter of them were on anticoagulant treatment (N.=9, 25%). The mean thrombin injection dose was 1000 U (range, 500-1500 U). In 34 of 35 (97.1%) patients, a thrombin injection resulted in complete thrombosis of the pseudoaneurysm lumen within a few seconds. There were no complications or recurrence of pseudoaneurysm after UGTI during the follow-up period. Conclusions Throughout the study period of 14 years, we did not encounter any procedural complications or arterial pseudoaneurysm recurrence. This is attributed to a safe procedural technique and proper patient selection. UGTI for arterial pseudoaneurysms is a safe, successful, and convenient treatment for both patients and surgeons.

Infection with Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012 as an important respiratory disease with high fatality rates of 40%–60%. Despite the increased number of cases over subsequent years, the number of pediatric cases remained low. A review of studies conducted from June 2012 to April 19, 2016 reported 31 pediatric MERS-CoV cases. In this paper, we present the clinical and laboratory features of seven patients with pediatric MERS. Five patients had no underlying medical illnesses, and three patients were asymptomatic. Of the seven cases, four (57%) patients sought medical advice within 1–7 days from the onset of symptoms. The three other patients (43%) were asymptomatic and were in contact with patients with confirmed diagnosis of MERS-CoV. The most common presenting symptoms were fever (57%), cough (14%), shortness of breath (14%), vomiting (28%), and diarrhea (28%). Two (28.6%) patients had platelet counts of < 150 × 109/L, and one patient had an underlying end-stage renal disease. The remaining patients presented with normal blood count, liver function, and urea and creatinine levels. The documented MERS-CoV Ct values were 32–38 for four of the seven cases. Two patients (28.6%) had abnormal chest radiographic findings of bilateral infiltration. One patient (14.3%) required ventilator support, and two patients (28.6%) required oxygen supplementation. All the seven patients were discharged without complications.

Ruptured renal artery aneurysm (RAA) during pregnancy is unusual, and its presentation is often misdiagnosed or delayed in diagnosis. With its high and preventable feto-maternal mortality, RAAs during pregnancy requires a quick and accurate diagnosis to be managed efficiently. We present a rare case of RAA during labor, managed intra-operatively after a successful caesarian section delivery. We conclude that a multidisciplinary approach with a high margin of suspicion is necessary to improve the outcomes of this occurrence.

We report a 16-year-old boy who sustained a gunshot injury on his upper left side of the chest that resulted in an injury to the left axillary artery and was treated with endovascular repair. An endovascular repair has been increasingly accepted for the management of hemorrhage in critically ill trauma patients; using covered endovascular stents provides an alternative modality for both controlling hemorrhage and preserving flow.

Background This study aims to evaluate the effectiveness of ultrasound-guided thrombin injection versus ultrasound-guided compression repair in the management of iatrogenic femoral artery pseudoaneurysms. Methods Between June 2006 and December 2015, a total of 29 consecutive patients (15 males, 14 females; mean age 54 years; range 26 to 81 years) with a femoral pseudoaneurysm treated by ultrasound-guided thrombin injection were retrospectively analyzed. These patients were compared with a historical group of 36 patients (21 males, 15 females; mean age 44 years; range 32 to 65 years) who underwent ultrasound-guided compression repair between February 1999 and May 2006. Medical records and vascular laboratory findings of all patients were reviewed. Successful treatment was defined as complete cessation of flow into the false lumen with preservation of flow in the femoral artery. Results The ultrasound-guided thrombin injection showed a success rate of 100%, whereas ultrasound-guided compression repair had a success rate of 80.5%, which was possibly affected by anticoagulant therapy, hypertension, and an aneurysm size of >6 cm. However, none of these factors did not affect the success of thrombin injections. Conclusion Ultrasound-guided thrombin injection is a highly successful, easy to perform, accepted, and well-tolerated method by patients. It is more effective compared to compression therapy in patients with hypertension, large aneurysms, and who are on anticoagulant therapy.

Highlights • Axillary artery aneurysms are an uncommon upper extremity pathology and Arteriovenous malformations (AVMs) are a rare cause. • We present a case of congenital high-flow AVMs in the upper limb who presented with an asymptomatic axillary artery aneurysm. • Our patient was asymptomatic, but surgery was indicated because of the size of the aneurysm. • We used a vein graft instead of a synthetic graft because the aneurysm was located close to the shoulder joint., Introduction and importance Axillary artery aneurysms are an uncommon upper extremity pathology. While trauma is the most common cause, degenerative aneurysms may occur in high-flow vascular conditions, such as upper extremity arteriovenous fistulas. Arteriovenous malformations (AVMs) are a rare cause. Case presentation and discussion We herein describe a 41-year-old male with multiple congenital high-flow AVMs in the left upper extremity who presented with an asymptomatic axillary artery aneurysm. The aneurysm was successfully treated with open resection and revascularization using a reversed basilic vein interposition graft. Conclusion Clinicians should be aware of the possibility of an axillary artery aneurysm in patients with upper extremity AVMs.

Summary Background A case control study to better characterize the clinical features, laboratory, and radiological abnormalities associated with MERS-CoV infection in order to help with early identification of this syndrome from other respiratory infections. Methods Eighty patients admitted to a hospital in Riyadh, diagnosed with MERS-CoV infection based on RT-PCR were matched on age, sex, and the presence of a co-morbid condition on a basis of 1:2 to other patients admitted with respiratory symptoms and tested negative for MERS-CoV on RT-PCR. Results None of the reported MERS-CoV presenting symptoms was significantly associated with being infected with MERS-CoV. On the other hand, WBC count was significantly lower in patients with confirmed MERS-CoV infection (median 5.7 vs 9.3, P: 0.0004). Neutrophil count was as well significantly lower in MERS-CoV patients (median 3.7 vs 6.7, P: 0.0001). Both AST, and ALT values were significantly higher in MERS-CoV infected group (AST median 42 vs 36, P: 0.03, and ALT median 33 vs 28, P: 0.003). Overall our MERS-CoV mortality rate was (10%) below the national figure of (40%). Conclusions None of the presenting symptoms are specific for MERS-CoV infection. And out of all the investigations WBC, neutrophil counts, AST and ALT values have some predictive utility.

We report a case of a 32-year-old male patient who developed unilateral lower-limb compartment syndrome following a long surgical procedure during which intermittent pneumatic compression was used as deep-venous thrombosis prophylaxis. This complication of surgery is associated with significant morbidity. Previously published reports have suggested the possible risk factors and a way to reach a diagnosis at an early stage. The possible risk factors we present are the long operative time and the use of intermittent pneumatic compression as deep-vein thrombosis prophylaxis. These findings could be used to raise awareness in early diagnosis and treatment.

Coinfection of Middle East respiratory syndrome coronavirus (MERS-CoV) with tuberculosis (TB) has not been previously reported. Here, we present 2 cases with both MERS-CoV and pulmonary TB. The first case was a 13-year-old patient who was admitted with a 2-month history of fever, weight loss, night sweats, and cough. The second patient was a 30-year-old female who had a 4-week history of cough associated with shortness of breath and weight loss of 2 kg. The 2 patients were diagnosed with pulmonary TB and had positive MERS-CoV. Both patients were discharged to complete their therapy for TB at home. It is likely that both patients had pulmonary TB initially as they had prolonged symptoms and they subsequently developed MERS-CoV infection. It is important to carefully evaluate suspected MERS-CoV patients for the presence of other infectious diseases, such as TB, especially if cohorting is done for suspected MERS-CoV to avoid nosocomial transmission.

Rationale: This report aimed to present the long-term follow-up results of the management of superior vena cava (SVC) rupture during balloon angioplasty in an attempt to relieve SVC obstruction as a result of hemodialysis (HD) catheter-related central vein stenosis. Patient concerns: We present a case of a 42-year-old woman with end-stage renal disease on HD for 4 years, initially from an autogenous fistula for 2.5 years and then from a right internal jugular vein (IJV) catheter. She presented with clinical manifestations of SVC obstruction (dilated anterior chest wall and abdominal wall veins and facial swelling), which progressed over the last 1.5 years. Diagnosis: A venogram confirmed right and left brachiocephalic vein and SVC obstruction. Interventions: She underwent balloon angioplasty of the SVC through the right IJV, during which the dilated area ruptured, resulting in right hemothorax and hypovolemic shock. A covered stent was placed over the bleeding site, and the patient recovered. Outcomes: Rapid and skilled endovascular intervention through placement of a covered stent at the bleeding site can be lifesaving. Lessons: It is superior to open surgical management in terms of complexity and morbidity especially in patients who are poor surgical candidates, and its durability is proving to be comparable.

Objectives: Intracorporeal injections (ICIs) of vasoactive substances during penile Doppler ultrasound (PDU) are a common investigation for erectile dysfunction (ED) diagnosis. ICI can be responsible of priapism, a pathological condition of prolonged penile erection not related to sexual stimulation. The aim of our study is to investigate the effectiveness of physical exercise and medical treatment as noninvasive therapy to restore detumescence in prolonged erections after ICI. Materials and Methods: Data were prospectively collected on men undergoing PDU in three urological centers. Three hundred and sixty-nine patients underwent PDU for the investigation of ED. All the participants received an ICI of quadrimix; prostaglandine E1, papaverine, phentolamine, and atropine. The data of the patients have been analyzed to record their comorbidities, results of PDU, and the complications encountered. Results: Fifty-three patients (14.4%) developed prolonged erections. Physical exercise alone was successful in reversing prolonged erection within 30 min in 21 (39.6%) patients. Out of the remaining 32 patients, oral salbutamol induced detumescence in 18 (34%) within the observation period of 60 min. Nonresponders were managed successfully with aspiration and irrigation of corpora with saline (11 patients, 20.75%) or with Phenylephrine (three patients, 5.66%). Conclusions: Physical exercise and oral salbutamol are safe and effective in restoring detumescence of pharmacologically-induced priapism. Noninvasive therapy may save a significant number of these patients an invasive treatment.

The aim of this study was to report the five-year incidence of incisional hernia after vascular repair of abdominal aortic occlusive (AOD) and aneurysmal disease (AAA), and to determine the factors associated with the development of this complication. Consecutive patients who underwent AAA and AOD at the University of Manitoba, Canada, between January 1999 and December 2002, were recruited and evaluated by clinical examination one week, one month and six months after the surgery, and through medical records review thereafter. The development of postoperative incisional hernia was recorded and analyzed. Two-hundred four patients, with a mean age of 70.1 years, provided consent for the study. The overall five-year incidence of incisional hernia was 69.1% and the overall median failure time was 48 months. The median failure time was 48 months for AOD and 36 months for AAA ( P < 0.01). The urgent and ruptured AAA repair had a higher five-year incidence of incisional hernia as compared with AOD or elective AAA repair ( P < 0.01). A history of bilateral inguinal hernia was significantly associated with incisional hernia ( P < 0.05). Men and patients who were 65 years and older had a higher five-year incidence of incisional hernia ( P < 0.01). Age ≥65 years, male gender, hypertension and past bilateral inguinal hernia repair double the risk for the development of incisional hernia (hazard ratio = 2.1. 2.2, 1.7 and 2.8, respectively). In conclusion, the five-year incidence of incisional hernia after vascular repair of AOD or AAA is 69.1%, and tends to occur late after vascular repair.

Background: Peripheral Arterial Disease (PAD) is a marker of systemic atherosclerosis with an elevated risk of cardiovascular mortality and morbidity. This study was undertaken to identify the prevalence of PAD in patients presenting with acute coronary syndrome and do not have previous history of coronary artery disease in order to identify the missed opportunity in treating these patients and potentially avoiding such cardiovascular events. Methods: We prospectively collected data from consecutive patients who presented with acute coronary events over 4 months. PAD was diagnosed if the Ankle-Brachial index was less than 0.90 and/or if the patient had signs or symptoms suggestive for PAD. Risk factors and risk reduction therapy were compared between patients with and without PAD. Results: A total of 51 patients were recruited. The mean age for these patients was 62 years and 27% were women. Prevalence of PAD was 45%, of these, 61% were asymptomatic. Prevalence of PAD in patients with no previous history of CAD was 48%, of these, 64% were asymptomatic. There was no difference in atherosclerotic risk factors between patients with PAD compared to patients without PAD. Utilization of risk reduction was suboptimal in patients with PAD; only 61% were on aspirin, 48% were on statin therapy, 43% were on beta-blockers and 30% were on angiotensin converting enzymes inhibitors. Conclusion: There is a great opportunity in preventing acute coronary events that we are missing. This is can be achieved by recognizing patients with PAD (symptomatic or asymptomatic) and aggressively control their risk factors.