Critical Limb Ischaemia

Case study

■ To further illustrate this notion, a case-example is given of a patient presenting to the wound clinic after smoking cessation 3 years prior for progressive wounds. Additional pertinent information includes recent angiogram and stent placement, tibial run off, and an ABI 0.65.The patient was evaluated and brought to the operative suite for wound debridement using ultrasonic debridement (Misonix, Farmingdale NY, United States) with a polyhexamethylene biguanide solution. Initial consultation and post-operative debridement is shown in Figure 4 and Figure 5, respectively

■ Following debridement, the patient was prescribed moist-to-moist hypochlorous acid (Vashe®, Urgo Medical North America, Fort Worth, TX), changes 3 times daily while in the hospital in addition to a robust micronutrient regimen including: 1 mg folate daily, 1 mg vitamin B12 daily, 10,000 IU vitamin D daily, 1 tablet MPFF twice daily, and 2,000 IU vitamin C Daily. She was prescribed IPC (ArtAssist® AA-1000, ACI Medical, San Marcos, California, United States) use dosing for a total of 6 hours daily with her leg in a gravity dependent position. Initially, the patient could not tolerate compression on the affected right side due to pain and was only applied to her unaffected contralateral limb. After approximately 3 weeks, granulation tissue on the affected right leg improved with decreased pain, allowing bilateral IPC compression use

■ The goal of using the IPC device on the unaffected limb was to establish a systemic increase in NO production for possible benefit in the wound dependent limb until IPC could be tolerated. Direct manual-lymph drainage (MLD) was also utilized like dermal stimulation with fuzzy-whale 8mm longitudinal compression (Edemawear®, Quart Medical, Kitchener, Ontario, Canada). Edemawear® works through dermal microdeformation, similar to the effects seen in negative pressure wound therapy (NPWT) that has been well documented to support wound healing37,38

■ Microdeformation in the totality of the wound bed results in a pulling shear force stimulating GCX restoration and biofluid movement. This concept was validated in a recent murine model study, but also highlighted the stimulation to endothelial GCX regeneration is vitally linked to the lymphatic regeneration capabilities which resonates with the improve fluid mobility seen in the patient.39 IPC use in patients with CLTI also stimulates the lymphatics, which would teleologically be appropriate given the decreased rates of cellulitis, improved angiogenesis, and dermal regeneration seen, all of which relate to lymphatic system functionality

■ This regimen provides a well-tolerated form of compression for patients with ABIs of 0.4 and above. As the 8mm compression is not constrictive, it is well tolerated by patients with pain. Functionally, there are benefits from the effects of stimulating dermal lymphatic functionality, decreasing interstitial edema in cases of extreme CLTI, and therefore increasing microvascular perfusion at the 5-micron level with resolution of underlying interstitial edema