Researchers test treatment  for cases where intervention, reconstruction failed

 Patients with peripheral arterial disease are often treated with intermittent pneumatic compression (IPC) to achieve leg inflow enhancement and improvement of claudication. However in patients with chronic critical limb ischemia (CCLI), who have tissue loss and non-healing wounds of the foot, face a below-knee amputation if all other vascular procedures have been exhausted.  

 
Steven J. Kavros, DPM, assistant professor of Podiatric Medicine at Mayo Clinic in Rochester, Minn., led a team of clinicians who evaluated the clinical efficacy of IPC in CCLI patients who had lost tissue and were not healing. In each of the cases, all possible vascular reconstructive and interventional procedures had been done or were not able to be redone due to medical health or past failure. Results were published in the March 2008 issue of the “Journal of Vascular Surgery.”

Between 1998 and 2004, this retrospective study reviewed data from two groups, each consisting of 24 consecutive patients. Performed in a community and multidisciplinary health care clinic, Group I patients (median age 70 years) was comprised of patients who received IPC for tissue loss and non-healing wounds of the foot attributable to CLI, in addition to wound care. Group 2 (median age 69 years) had the same care but without IPC. Patients were followed for 18 months after their minor foot amputation and outcome was considered favorable if complete healing and limb salvage (minor foot amputation of the toe, metatarsal or forefoot) occurred, and adverse if the patient had to undergo a below-knee amputation (BKA) subsequent to failure of wound healing.

In the non-IPC group, 20 patients failed to heal their minor foot amputation and underwent a BKA; the remaining four had complete foot healing and limb salvage. In the IPC group 14 patients had complete healing and limb salvage after a minor foot amputation; the other 10 patients in this group underwent BKA after failing to heal. Also, patients with transcutaneous oxygen of the foot in dependency had an improved rate of successful limb salvage if the value was 20-40 mmHg, even if their levels in the supine or elevated position were below 20 mmHg.

Dr. Kavros added that data indicated that statistically, if BKA is done on a diabetic, they have a 50 percent chance of having a BKA of the other limb in three years and a 40 to 50 percent chance of a cardiovascular death in three to five years.

“Our patients were followed for 18 months,” Dr. Kavros said. “Our results show the efficacy of IPC implementation when used as an adjunct to wound care in patients with CCLI undergoing a minor foot amputation instead of moving directly to a below-knee amputation.

This significantly reduced a major amputation (below-knee amputation) in patients where all established vascular treatment alternatives have been exhausted, improving the likelihood of limb salvage. Although our study adds the momentum of IPC clinical efficacy set by previous studies, the pursuit of large scale multi-centric level-1 studies to substantiate IPC’s actual clinical role, relative indications, and to enhance our insight into the pertinent physiological mechanisms, would be recommended.

For more information about the Society of Vascular Surgery, see VascularWeb.org. For more information about the “Journal of Vacular Surgery,” see jvascsurg.org. VTN