When All Else Fails, Don’t Give Up: Be Creative!

Arterial insufficiency can be a thorn in a wound care provider’s side. We know that for a wound to heal, adequate blood supply to the tissues must be present. But how much blood flow is adequate for healing to occur, and how do we measure it? We know there are tests to measure extremity blood flow, with the ankle/brachial index (ABI) being the most widely performed and accepted. We’re told arterial insufficiency begins with an ABI below 0.8, and healing will not occur with an ABI below 0.5. When this is found, we rush to treat the patient with either a bypass operation or an endovascular procedure. I would be the first to agree that it’s good to provide more blood flow to an extremity to help heal a wound. Unfortunately, there are patients for whom these procedures cannot be done. The most common reasons given for patients not undergoing revascularization include medical comorbidities (they are too sick) or absence of a suitable outflow vessel to open or to attach a graft (their vessels are too bad). These patients are generally sentenced to a major limb amputation. I can understand an amputation for the second reason, but it has always been my opinion that if a patient is too sick for a revascularization procedure, the patient is too sick for an amputation! The mortality rates for revascularization procedures have always been less than those for a major limb amputation. So, what do we recommend? It’s time to get creative!

In this month’s Evidence Corner, Dr. Laura Bolton brings us some creative answers. The review of autologous cell therapy using mesenchymal stem cells, bone marrow cells, or others to stimulate the formation of new blood vessels and improve ischemia is very informative. I’ve been talking about this technology since the report of clinical success in the Lancet in 1996.¹ We actually had a patient with a lower leg ischemic ulcer participate in the trial. He received the gene therapy, had relief of his rest pain, and healed his ulcer. I feel this is the future for severe, unreconstructable vascular disease and hope it will become “mainstream” very soon. 

What are we to do until we have access to that therapy? Dr. Bolton again points out the creative use of negative pressure wound therapy to treat diabetic ulcer patients. The review and meta-analysis show there is a 48% increase in the chances the diabetic ulcer will heal.²

Others thinking creatively have used intermittent pneumatic compression therapy to help increase blood flow in ischemic limbs when revascularization has not been an option. Montori et al³ reported a 40% healing rate when patients with nonhealing wounds and vascular insufficiency were treated with intermittent pneumatic compression. This improved healing in ischemic limbs without revascularization while using intermittent pneumatic compression was confirmed by Alvarez et al⁴ when they found a wound surface area reduction of 71% at 16 weeks in patients using the therapy compared with only 56% for those not receiving the therapy.  

When all else fails, think creatively and return to the basics of wound care. McCulloch et al⁵ showed that patients with ulcers and ischemic limbs who could not undergo revascularization could be treated with “good wound care” (needed debridement, offloading, bacterial control, and moist wound healing) and have a healing rate of 66% after 16 months of therapy. Only 15% of this group required a major (above knee or below knee) amputation at the end of 12 months.⁵ Even more creative thinking occurred when Marston et al⁶ realized that using platelet-derived growth factor (PDGF) might stimulate new vessel formation in the wound bed of ischemic diabetic ulcer patients and improve healing. Their treatment of this group of patients with good wound care and becaplermin (PDGF) resulted in a 64% wound closure at 6 months and an amputation rate of only 17%.⁶ Our work using growth factors provided by bilayered tissue-engineered skin in the treatment of these seemingly hopeless wounds has shown similar results.⁷

Patients with unreconstructable vascular disease and moderate ischemia should not be automatically sentenced to a major amputation. With the technology available today, we can treat most of these patients and get a satisfactory outcome. Don’t you think our patients deserve that? Remember, when all else fails: don’t give up. Use your knowledge of treating wounds and be creative.