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The Role of Technology in Managing Vascular Wounds 25
existing arterial ulcers (Gonzalez et al. 2016). Before deciding which revascularization technique to use, the arteries of the affected limb need to be examined to
determine where the sites of occlusions. This can be done by a doppler-ultrasound
examination or by angiography using contrast agents and either conventional X-ray,
computer tomography or magnetic resonance imaging. Most contrast agents can
affect kidney function and patients with advanced renal disease may not be candidates for an angiography. It is possible to do a selective angiography of only the
affected limb, thus reducing the volume of required contrast agent. Modern vascular
centres can perform angiographies using CO
as a contrast agent, which can be used
2
even in patients with severe renal disease (Thomas et al. 2021).
Depending on the localization and the extent of the occlusions it is determined
whether revascularization can be achieved by minimally invasive (endovascular)
techniques or whether conventional, open surgery is required. In patients with
extensive occlusions in several main arteries of the leg, revascularization may not
be possible at all, especially if the patient is older and has other significant
comorbidities. These are briefly discussed:
(I) Percutaneous Transluminal Angioplasty (PTA)
When the localization and extent of the occlusions allow it, a PTA is the preferred
treatment modality for PAD/LEAD. This minimally invasive technique is performed under local anesthesia. In many centers this is performed by invasive
radiologists. The arteries are usually accessed in the groin area using Seldinger
technique. A guide wire is introduced, and an inflatable balloon is advanced to the
occlusions. The balloon is inflated thus opening the lum en of the affected artery
(balloon angioplasty) If possible a stent is placed in the lumen to prevent early
recurrence (Chavan et al. 2010). The term patency is used to describe how long the
lumen remains open after the procedure. Re-stenosis (or re-occlusion) of the treated
vessels is common (Chavan A, Luthe L, Schmuck B. 2010). Recent tools to
improve the results of PTA are drug-eluting stents and balloons, which have
resulted in better patency compared with conventional balloon dilatation or bare
metal stents (Zhang and Tong 2020; Rajaee et al. 2015).
While PTA is considered a relatively safe procedure, there are risks of complications. These include perforations with bleeding, infection or formation of a
pseudoaneurysm (Liu et al. 2020).
(II) Subintimal Angioplasty (SIA)
Subintimal angioplasty was first described in 1990 (Bolia et al. 1990). While a PTA
is performed in the lumen of the affected artery, SIA is done in the wall of the
artery. This is a technique that can be used when an artery is completely occluded,
and it is not possible to pass a guidewire or balloon past the occlusion in the lumen
of the artery. By creating a new lumen underneath the intima, the occlusion can be
bypassed. In a systematic Cochrane review published in 2016 it was, however,
concluded, that there is currently insufficient evidence to support SIA over other
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techniques (Chang et al. 2016). However, it may be the only solution when a PTA
is not possible or when a patient is not fit for open surgery.
(III) Open Surgery
The list of factors determining the indications for open surgery is long. The major
factors determining whether open surgery is indicated is the localization and the
length of the occlusions, the general condition of the patient, whether endovascular
procedures have been tried before and whether the patient has intact veins (often
greater saphenous vein) which can be used as an autologous graft. In some cases a
hybrid treatment method may be used where both endovascular and open surgery
are used simultaneously (Robertson et al. 2017).
Pharmaceutical Treatment to Improve Microcirculation in PAD/LEAD
Do anticoagulants enable blood to pass better through narrowed arterial lumens?
Unfortunately, however, this is not the case. Neither heparin, warfarin, NOAK,
clopidogrel or acetylsalicylic acid have been shown to lead to any significant
arterial perfusion changes in patients with PAD. Furthermore, there are no other
pharmaceutical products that has been shown to lead to a permanent increase of
arterial blood circulation. However, especially acetylsalicylic acid and clopidogrel
are recommended as standard therapy in patients with PAD to prevent cardiovascular complications due to general atherosclerosis (Bauersachs et al. 2020).
Vasodilators
In severe ischaemia, vessels are already maximally dilated consequent to local
release of vasoactive metabolites from ischaemic tissue. Vasodilators are unlikely to
improve flow and may worsen ischaemia by “stealing” blood flow to other tissues.
Controlled trials do not support their use.
Naftidrofuryl
Early trials with this vasodilator seemed encouraging, and an increase in tissue pH
in the skin of the ischaemic foot suggests that its metabolic effects on ischaemic
tissue may be beneficial. However, a literature review from 2011 concluded that its
place in PAD management remains to be established by further trials using endpoints directly beneficial to the patient (Squires et al. 2011).
Vasodilator Antiplatelet Prostaglandins
Various types of prostaglandin analogues have been evaluated since the early 90’s
and to-date there are no studies that support the use of these products in severe PAD
with arterial ulcers (Lambert and Belch 2013).
Pentoxyfilline
Pentoxifylline acts by decreasing blood visco sity, improving erythrocyte flexibility,
and promoting microcirculatory flow and tissue oxygen concentration. Many
studies have evaluated the efficacy of pentoxifylline in treating people with PAD,
The Role of Technology in Managing Vascular Wounds 27
but results of these studies are variable. To date, the routine use of pentoxyfilline
cannot be recommended in patients with PAD (Lambert and Belch 2013).
Angiogenic Growth Factors
Several angiogenic factors, including vascular endothelial growth factor (VEGF),
hepatocyte growth factor (HGF) and fibroblast growth factor (FGF) are under
investigation with respect to treating PAD/LEAD (Lambert and Belch 2013). These
treatments are still in their early experimental stages but may represent an important
treatment modality in the future.
Cell Therapies
To promote sufficient blood flow in diseased limbs in PAD patients, cell-based
therapy has been widely investigated. Among cell therapies, endothelial progenitor
cells (PCs), mononuclear cells (MNCs), mesenchymal stem cells (MSCs) and
embryonic stem cells (ES) have been investigated (Sprengers et al. 2010; Salybekov
et al. 2021). Although clinical studies are expected, no study has started owing to
the risk of carcinogenesis- and angiogenesis-specific separation procedures. Again,
this is a technology is currently not a realistic option for patients with PAD/LEAD
but one which is likely to be seen in future.
Management of Ischemic Limb Pain
Ischemic limb pain is a complex type of pain, and in advanced ischemia, allodynia,
hyperalgesia, and hyperpathia are commonly seen. Increasingly, it is realized that
the inflammation resulting from chronic poor perfusion is also associated with
neuropathic pain (Rüger et al. 2008).
Chronic advanced ischemic limb pain is a considerable challenge as most classes
of pain medication do not provide adequate pain relief. Once the ischemic disease
has advanced so far that the patient cannot sleep with the affected limb at bed-level
(positional pain), pain management is far more complicated. At this stage, the limb
has entered a vicious circle—by lowering the limb, the patient feels symptom relief.
Still, often this increases tissue edema, reducing arterial blood flow even more and
increasing inflammation.
In our experience, exercise to promote the development of collateral arteries is
only a useful adjunctive in mild to moderate ischemic limb pain. Once the disease
has progressed so far that the patient has positional pain and needs to keep the
affected limb in a dependent position, we need a more aggressive treatment plan.
Revascularization is the only possibility for permanent pain relief. However,
some patients may not be candidates for such a procedure, and palliative treatment
with pain medication may be the only alternative. Patients eligible for revascularization may have to wait several weeks before the procedure is performed, and
during that time, we also have to provide optimal pain relief. Some patients
experience early pain relief foll owing successful revascularization; in a few patients,
this effect may even be immediate right after the procedure has been done. In many
cases, however, pain levels may actually increase during the first weeks following
revascularization due to a reactive hyperperfusion. Furthermore, it is essential to
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realize that, even after successful revascularization, a significant number of patients
still have considerable chronic pain levels (Torbjörnsson et al. 2021).
As with pain management in general, the principles of the World Health
Organization (WHO) Analgesic ladder are applied. This pain treatment principle
has been under debate in the past decade, but most pain management programs still
build upon this (Riley et al. 2007; Vargas-Schaffer 2010). Most ischemic patients
should be provided with paracetamol as the ladder’s base. Note that non-steroidal
anti-inflammatory drugs (NSAIDS) usually are at least partially contraindicated in
ischemic patients as they often have concomitant heart- and renal disease. On step 2
of the pain ladder, it is common to try codeine or tramadolhydrokloride-based pain
medication. Tramadolhydrokloride should be avoided in elderly patients as it can
cause serotenergic side effects, especially when combined with certain other
medications (Hassamal et al. 2018). Step 3 of the pain ladder consists of the more
potent opioids. Most patients with advanced ischemic limb pain will require strong
opioids. The challenge here is that even strong opioids often do not provide adequate pain relief. Furthermore, the majority of patients with critical limb ischemia
are elderly and do not tolerate opioids very well.
The class of strong opioids is a very diverse group of products, and the effectiveness and tolerance of different opioids will vary significantly between patients.
If a patient does not experience adequate pain relief from one opioid even after
increasing the dosage, another class of opioids should be tried. Opioids can be
administered in several ways, and transdermal opioid patches (especially transdermal buprenorphine) may be a good solution for elderly patients (Laoire and
Murtagh 2018). Tapentadol may be more effective than several other opioid drugs
as it seems to address neuropathic pain better (Haro and Bleda 2019). Methadone
may also be a good opioid alternative in frail elderly patients and is particularly
useful in patients with poor renal function (Gallagher 2009).
In advanced ischemic limb pain, the WHO Analgesic ladder alone is often not
sufficient and adjunctive treatments are necessary. Using adjunctive therapies may
provide better pain relief and make it possible to use lower opioid dosages, thus
reducing their side effects. There is no clear common denominator of what
adjunctive pain therapy works best. Furthermore, many adjunctive drugs work
slowly; that is, it often takes weeks to determine whether a certain drug has any
effect. This is obviously frustrating for the patient. We strongly suggest engaging a
pain specialist at this point; ideally, a multi-disciplinary pain team should be
involved here as this patient group is particularly challenging.
Gabapentin is commonly tried as a first-line adjunctive (Laoire and Murtagh
2018; Morris-Stiff and Lewis 2010; Heartsill and Brown 2005). It is often started at
300 mg 3 and gradually titrated upwards over the course of a few weeks. It is
therefore advised to add gabapentin early as it requires this titration period. In our
experience, the drug should be discontinued if the patient does not experience
significant pain relief at 1800 mg daily dose within a few weeks.
Clonidine has, in recent years, received attention as an adjunctive treatment in
advanced pain management. It is a drug to treat hypertension but has an analgesic
effect and potentiates the effect of opioids (Nahman-Averbuch et al. 2016; Kumar
The Role of Technology in Managing Vascular Wounds 29
et al. 2014; Neil 2011). Literature on its role in the management of ischemic pain is
sparse. In the past two years, we have tried clonidine routinely on patients with
advanced ischemic limb pain and found that it provided significant pain relief in at
least 50% of patients at dosages from 25 µg 3 daily.
It is common also to consider the addition of an antidepressant (i.e., serotonin
and norepinephrine reuptake inhibitors or low-dose tricyclic antidepressants),
especially if depression is present or suspected. The documentation for their use in
ischemic limb pain is sparse, and experiences come primarily from studies on
diabetic neuropathy pain (Riediger et al. 2017;Nøkleby and Berg 2005; Sindrup
et al. 2005; Verdu et al. 2008; Obata 2017).
Vasodilator antiplatelet prostaglandin analogs seem to have limited effect in
advanced ischemic limb pain (Belch et al. 2011; Gaspar et al. 2016; Telles et al.
1984).
Several invasive techniques for pain management are available. One alternative
is epidural spinal cord stimulation which can be a useful adjunctive to other pain
management regimens (Cameron 2004; Pedrini and Magnoni 2007; Caridi et al.
2016). In a recent study by Cyrek et al., patients with Fontaine III ischemia ben-
efitted more from this treatment than patients with Fontaine Iv ischemia (Cyrek
et al. 2021).
As a short-term treatment, for example, in patients awaiting revascularization or
amputation, continuous peripheral nerve blocks (CPNB) or epidural opioid infusions should be considered if pain levels cannot be managed adequately by other
methods (Fernandes, et al. 2021;D’Souza et al. 2020). This treatment is usually
highly effective, but it may not be a long-term solution as the nerves sometimes lose
tolerance to the local anesthetic drugs over time—a phenomenon called tachyphylaxis (Klementová and Michálek 2018; Stienstra 2016). There is some debate
around tachyphylaxis—and several case reports document good effects of
long-dwelling catheters over extended periods (Bosco et al. 2012). CPNB appears
to be a safe, effective but paradoxically under-utilized tool to provide good pain
management for patients with advanced critical limb ischemia.
Diabetic Management
Topical Treatment of Arterial Ulcers
Much of topical treatment in wound care today is not evidence based. The reason for
this is that is it extremely difficult to perform good studies on patients with chronic
wounds. The list of confounding factors is very long and to achieve somewhat
homogeneous patient groups, the numbers needed to treat are often impractically
high. Most patients with advanced PAD/LEAD have several other comorbidities that
influence wound healing as well making it very difficult to interpret treatment outcomes. Most of our knowledge of treating arterial ulcers comes from general experience and expert opinion. In a recent Cochrane review, the authors concluded that
there is insufficient evidence to determine whether the choice of topical agent or
dressing affects the healing of arterial leg ulcer s (Broderick et al. 2020).
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Cleansing
For wounds that are considered to have adequate arterial perfusion, pH-balanced,
non-cytotoxic skin and wound cleaners should be used to maintain the skin’s
moisture barrier and acid mantle and promote a moist wound healing environment
(Bonham et al. 2016). Arterial ulcers that are considered to have adequate blood
flow to heal may benefit from the use of cleansers that contain antiseptics and
surfactants (Percival et al. 2017). The cleansing of non-healable arterial ulcers that
present with dry eschar or dry gangrene is not recommended (Hopf et al. 2008).
Dressing Choices
Maintaining a dry wound environment is recommended for difficult, non-healing
wounds, or until adequate blood flow has been re-established or the ischemic digit
auto-amputates. When an ulcer is considered non-healable because of inadequate
perfusion, it is strongly recommended that all sources of moisture, such as foot
soaks, creams and ointments, be avoided (Hopf et al. 2008; Aboyans et al. 2018).
The choices of dressings for potentially healable arterial ulcers depend on the
same factors we assess when choosing dressings for other chronic ulcerations. Our
choices depend primarily on the amount of exudate and the bacterial burden of the
wounds. Other factors influencing the choice of dressing are the size and depth of
the ulcers as well as their location. As there is no evidence-based consensus about
which topical treatment to use for arterial ulcers, experience and expert opinion
determine the best choices.
Currently, there is insufficient evidence to suggest that one particular dressing
over another will significantly affect the healing of arterial ulcers (Broderick et al.
2020). As mentioned earlier, moist wound healing and occlusive dressings are not
recommended for arterial wounds that do not have sufficient blood flow to heal.
However, dressings that provide good ventilation and permit frequent wound
inspection are recommended for arterial ulcers (Bonham et al. 2016).
(i) Keeping Dry Eschar Dry
This is a well-established principle of treating arterial ulcers. It is based on the
experience that when we try to debride dry eschar on arterial ulcerations this may
lead to new and more severe challenges. Without adequate perfusion to heal the
wound, debridement may exacerbate tissue ischemia by increasing metabolic
demand, leading to increased risk of amputation (Hopf et al. 2008; Chiriano et al.
2010). A dry eschar on an ulcer is usually easy to manage for the patient—there is
no exudate and there may not even be the need for any dressing, other to protect the
area from mechanical irritation from shoe wear.
It appears that the dry environment of dry eschar limits bacterial growth. If we
would debride the eschar, it will usually lead to nothing else than giving the patient
an open wound which may be more difficult to manage. In general, we avoid
occlusive dressings on dry eschar as these can change the situation from a dry
necrosis to a moist necrosis, increasing the chance of infection. We typically use
The Role of Technology in Managing Vascular Wounds 31
dry cotton gauze over dry eschar to protect the area while providing a dry, and airy
environment.
Many authors have recommended the daily application of povidone iodine (10%
PVP-I) to maintain a dry wound bed (Woo 2014; Landis 2008). It appears that the
iodine dries out the surface of the wound and change a moist wound into a dry
wound. In fact, cleaning a non-healable wound site before the application of 10%
PVP-I is not recommended (Federman et al. 2016). Gangrenous tissue, if not
infected, can form an eschar cap that will progressively shrink as it dries and
eventually “mummify.“ (Norgren et al. 2007) If the circulation beneath or surrounding the wound is adequate (or improved by a revascularization procedure), a
process of auto-amputation may follow (Norgren et al. 2007). This process, however, may take considerable time, and pain management, education in bacterial
burden, and maintaining a dry wound environment become the priorities (Norgren
et al. 2007; Woo 2014). The antibacterial and astringent dye gentian violet can also
be used similar to PVP-I (Applewhite et al. 2015; Farid et al. 2 011).
Debridement prior to revascularization in poorly perfused extremities should be
performed only in a septic foot with and without ischemic signs (Hopf et al. 2008).
(ii) Debriding Arterial Ulcers
If the arterial ulcer is not covered by dry eschar there is usually a layer of superficial
necrotic tissue or fibrin covering the wound bed. It is a general principle of wound
care that debridement of necrotic tissue and fibrin should be done to promote
wound healing. If we have established that we are dealing with a non-healable
ulcer, however, then the recommendation is not to debride it and rather dry out the
necrotic tissue with for example povidone-iodine.
In healable ulcers however, the general rules of debridement apply as with other
chronic leg and foot ulcerations. Since arterial ulcers usually are very painful this
must be done gently, preferably using a topical analgesic agent. In our experience
topically applied lidocaine gel or similar, applied about 20–30 min prior to
debridement is helpful. However, this will only anesthetize the upper layers of the
wound and does not allow a deeper debridement. In many cases a serial debridement may be indicated, debriding a little at each consultation. In more severe cases,
where there is more extensive moist necrosis and possibly even infection, a more
through debridement may be indicated. This may involve the need for a regional
block or even general anesthesia.
In select cases maggot debridement therapy (MDT) can be used when there is
moist necrotic tissue. Maggot therapy is usually quite painless and can be a good
alternative to sharp debridement. There is very little evidence concerning MDT and
arterial ulcers. In a small study by Igari et al., MDT was effective when used in
arterial ulcers but patients with an ABI lower than 0.6 were less likely to benefit
from the treatment (Igari et al. 2013). In our opinion, most arterial ulcers do not
need MD T as there usually is not much necrosis. However, we routinely use MDT
to salvage complications after attempted toe amputations or even major
amputations.
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Using occlusive dressings like hydrocolloid dressings to promote autolytic
debridement in arterial ulcers is not recommended because of an increased risk of
infection (Bonham et al. 2016). Instead, the general principle of providing the
wound bed with adequate moisture levels to support autolytic debridement and
promote granulation tissue formation are used. Regular polyur ethane foam dressings are commonly used as topical management for arterial ulcers. They absorb
reasonably well and provide a moist wound environment making them a safe choice
for most situations in healable arterial ulcers.
(iii) Arterial Ulcers with Increased Bacterial Burden
While diabetic foot ulcers usually have a high bacterial burden, this is not necessarily the case for arterial ulcers. However, it is suggested that the diminished
micro-perfusion encourages the development of biofilm in arterial ulcers (Drago
et al. 2019).
The application of topical antimicrobial dressings should be considered to
minimize the proliferation of bacteria in the open wound and possibly even under
dry eschar (Hopf et al. 2008; Bonham et al. 2016). Povidone iodine (10% PVP-I).
PVP-I is one of the most extensively used broad-spectrum topical antiseptics used
to minimize the bacterial burden in long-standing wounds with an inadequate blood
supply (Woo 2014). PVP-I is available in an aqueous solution, as well as being
impregnated into products that have a sustained-release delivery system. However,
it is important to consider that formulations of PVP-I, such as liposome hydrogel
(3%) and cadexomer-iodine (0.9% iodine), may enhance moist woun d healing and
may not be appropriate for non-healing arterial ulcers (Woo 2014).
(iv) Infected Arterial Ulcers
As with diabetic foot ulcers, signs of infection are not always apparent in arterial
ulcers. The typical signs of increased redness and increased local temperature in the
wound area may be absent due to reduced microcirculation so it is important to
have a high level of suspicion. When infection is suspected in arterial ulcers we
have a low threshold for antibiotic therapy, but a bacterial swab should always be
taken first.
When it is suspected that an arterial ulcer has become infected, the use of a
topical antimicrobial dressing is not considered to be sufficient treatment (Bonham
et al. 2016). Systemic antibiotic therapy is required in patients with CLTI who
develop spreading or systemic infection (Bonham et al. 2016). Clinical signs of
infection may be subtler because of the decrease in blood flow to the site of the
arterial ulcer (Bonham et al. 2016). Clinical infection should be suspected when the
ulcer becomes more painful, or the local wound site begins to deteriorate or fails to
heal (Federman et al. 2016). PAD/ LEAD-related wound infection is a primary risk
factor for major amputation (Mills et al. 2014; Prompers et al. 2008).
It is recommended that a patient with PAD and CLTI be referred promptly to a
vascular surgeon when infection is suspected (Anderson et al. 2013; Hirsch et al.
2006; Lipsky et al. 2012). Best practice guidelines recommend that patients with
The Role of Technology in Managing Vascular Wounds 33
CLTI, skin ulcerations and evidence of limb infection be promptly treated with
systemic antibiotics (Anderson et al. 2013; Hirsch et al. 2006; Lipsky et al. 2012).
A patient with an infected arterial ulcer should be evaluated as soon as possible by a
clinician with expertise in determining the appropriate culture-guided antimicrobial
treatment (Federman et al. 2016). Wound cultures and tissue and bone biopsies can
guide culture-specific treatment. Where no cultures are available, or prior to culture
processing, empiric broad-spectrum antibiotics should be initiated in consul tation
with an infectious disease specialist whenever possible. Adjustment of antibiotics
should be made once the causative micro-organisms and culture and sensitivity
have been obtained (Lipsky et al. 2012; Stevens et al. 2014). Additional caution
should be exercised when prescribing antibiotics to a patient with renal insufficiency to ensure effective clearance of these medications. In such cases, consultation with a nephrologist, or pharmacist for renal dose calculations, may be
warranted to ensure patient safety.
(v) Negative Pressure Wound Therapy (NPWT)
While there is a fair amount of evidence to support the use of NPWT in the
treatment of diabetic foot ulcerations and venous leg ulcers, this is not the case for
patients with ulcerations and concomitant ischemia (Ji et al. 2021). There are
concerns that patients with ischemic wounds may develop worsening necrosis with
NPWT if wounds are not well vascularized but studies have yet to establish this
notion of precipitating necrosis with NPWT.
In a study by Kasai and colleagues, the authors applied lower pressures of
−50 mmHg to ischemic wounds, and all healed without further necrosis at wound
edges (Kasai et al. 2012). The thought process governing this was that capillaries at
wound edges would likely occlude at pressures as high as −125 mmHg so ischemic
wounds treated with lower pressures would reduce the tissue pressure and promote
healing,
In the absence of further evidence concerning the use of NPWT in arterial ulcers,
we will presen t our own experiences here. We agree with Kasai et al. that it appears
safer to use lower pressure settings when treating arterial ulcers. The effectiveness
of NPWT is not necessarily proportional to the amount of negative pressure
applied. So me manufacturers use −80 mmHg as the default setting, others use
−125 mmHg. However, pressures even as low as −40 mmHg can be effective for
wound treatment. (Vikatmaa et al. 2008).
NPWT does not aid in the epithelialization of wounds. NPWT is used to promote
the formation of granulation tissue. If we have a healable arterial ulcer that appears
to have the potential to form granulation tissue, NPWT may be indicated. We
routinely use −50 mmHg as the pressure setting and use intermittent therapy where
we commonly have a three minute on, one minute off treatment cycle. It is our
hypothesis that the one-minute pause from negative pressure allows the microcirculation in the wound bed to return to normal. Again, these recommendations are
expert opinion based, and we have no scientific data to back-up our recommendations. We find it hard to predict the outcomes of using NPWT in patients with
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arterial ulcerations and severe ischemia and this treatment method should be used
cautiously and only in experienced hands. Ischemic skin does not tolerate moisture
very well—moisture associated skin damage from prolonged use of NPWT (occlusive plastic drape) is also a common problem in our experience.
In our opinion, NPWT is however, extremely useful for salvaging failed
amputations in patients with PAD, particularly at the leg or thigh level. These are
situations where there may have developed necrosis of the amputation site,
sometimes requiring quite extensive debridement leaving behind large tissue
defects. We have routinely used NPWT to manage these complications, often with
success and in this way have prevented a new amputation at a higher level of the
extremity.
Hyperbaric Oxygen Therapy (HBOT)
Most of the literature available focuses on HBOT for diabetic foot ulcers with and
without arterial insufficiency. In this population the role of HBOT remains unsure.
In a recent systematic review and meta-analysis, the authors concluded that adjuvant HBOT improves major amputation rate, but not wound healing, in patients
with DFUs and PAD (Brouwer et al. 2020). Given the wide range of patients
included in the trials, better patient selection may help define which patients with
DFUs and PAD benefit most from HBOT as standard adjunctive treatment
(Brouwer et al. 2020). Concerning arterial ulcers alone we have no evidence today
to justify its use in patients with this condition.
Topical Hyperbaric Oxygen Therapy (TOT)
TOT involves placing the affected limb in a sealed chamber and introducing 100%
oxygen under higher than atmospheric pressure (Frykberg 2021). A recent systematic review on the impact of topical oxygen therapy on diabetic foot ulcer
healing rates concluded in favor of this technology (Connaghan et al. 2021). Their
findings suggest that TOT enhances healing for patients with hard-to-heal DFUs
when used with standard care. However , the sample sizes in the studies were
generally small, thus, more RCTs are warranted to further validate these findings.
As with HBOT there is scarcity of literature about the efficacy of TOT in arterial
ulcers without DM.
Autologous Platelet Rich Plasma (PRP)
PRP is a simple treatment modality—blood is drawn from the patient and centrifuged in a manner to concentrate the platelets in a layer also called “buffy coat”
The platelet concentrate is then placed directly on the wound bed. There is sufficient
evidence for using PRP in diabetic foot ulcers (Hirase et al. 2018;Huetal.2019),
but the role of the treatment in arterial ulcers remains unclear. There are only few
studies done to this respect. In a recent study by Chandawale et al. 80 patients were
randomized to PRP treatment or conventional dressings. The results showed a
significant faster reduction of ulcer size and epithelialization in the group treated
with PRP (Chandanwale et al. 2020). Further studies are need to confirm these
results.
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