AdequateWoundCareafterEndovascularTherapy:AKeystonetoSuccess

VickieRDriver,DPMMSFACFAS

FacultyDisclosuresVickieRDriver:Consultant– MosaicBiosciences,3oTechnologyNoproductonmarket

OtherFinancialorMaterialSupport– FormeremployeeofNovartisBioMedical Research,MediWoundboardmember

Brandnamesareincludedinthispresentationforparticipantclarificationpurposesonly.Noproductpromotionshouldbeinferred.

Objectives:

Take away:

1. Understand key elements of wound careSurgery, debridement, off loading and advanced

therapies.2. Understand how to incorporate wound

care basic to improve patient outcomes…………………………………………………ü Understand that wound care is never basic

when it comes to CLI patients. ü It requires advanced early care before and

after vascular interventions

The Clinical Landscape

• Vascular Specialist/Surgeons • Podiatric Surgery• Plastic Surgery• Medicine/Endo• NP/PA• Nursing• Dermatology• Radiology • Infectious Disease • PT/OT

Advanced Care Practices for High Risk: Team Approach

Limb Preservation: Treatment Principles

•Aggressive treatment of infection – surgical•Diagnose ischemia and refer – intervention•Relief of pressure to wound – offload•Improve wound environment with debridement and advanced care treatments•Discover new ideas with research

Driver VR, et al. Diabetes Care. 2005;28(2):248-253.

• Setting of care- Experience / knowledge of provider(s)

• Type of wound and its chronicity• Health status of patient / comorbidities• Concomitant medications may interfere• Timely selection of interventions that address defects

in wound microenvironment

Many Factors Affect Wound Care Outcomes

Adequate Wound Care

• Pressure Control • Surgical or Conservative

• Debridement• Infection Management• Wound Care• *** Team Player

Adequate

TCCissupportedbylevelIevidence

RCTs,twometa-analyses,andaCochranereview

TCC = total contact casting.

How Does it Work?

� TCC decreases pressure in 1st

met by 69% and decreases heel pressure by 45%

� Full contact with weekly custom fit cast provides control of shear

� Reduced foot pressure and shear allows skin to heal

� Ensures 100% compliance

Wertsch JJ, et al. J Rehabil Res Dev. 1995;32(3):205-209.

No TCC (n=10) TCC (n=10)

IS IT POSSIBLE TO IMPROVE THE OUTCOME?

Semiquantitative analysis of histological features of neuropathic DFU: Effect of pressure relief

HYPERKERATOSIS

FIBROSIS

CAPILLARIES

INFLAMMATION

GRANULATION

2.8

2.8

0.5

3

0.2

1.8

1.8

2.5

1.1

2.8

DFU = diabetic foot ulcer.Piaggesi A, et al. Diabetes Care. 2003;26(11):3123-3128.

SCORE: 0, absent; 1, present in <33%; 2, present in 34-66%; and 3, present in >67% of the lesion

Adequate Wound Care

• Pressure Control • Surgical or Conservative

• Debridement• Infection Management• Wound Care• *** Team Player

Schutz GS, et al. Wound Repair Regen. 2003;11(Suppl 1):S1-S28.

Physical Barrier

In chronic wounds, dead tissue is unreceptive

Growth factors are stimulated, and micro-healing can begin

Necrotic tissue: Physical barrier for GF receptors

Mulder GD, et al. J Am Podiatr Med Assoc. 2002;92(1):34-37.

93 yo Diabetic Male Ulcer – Osteomyelitis - CLI Post Intervention ABI .25 TO .5

CLI = critical limb ischemia; ABI = ankle-brachial index.

Real World CLI Immediate-Post Vascular Intervention

Necrosis and Bone

TIMING:

TWO SITUATIONS

Liquefactive necrosis

1. Transformation of the tissue into a liquid viscous mass.

2. Often associated with focal bacterial or fungal infections

3. Neutrophils release hydrolytic enzymes which attack the surrounding tissues.

Function restored decrease shear force

silicone mold slipper liner

§§§§

Are we done yet?

Venous Stasis Ulcer

Excessive inflammatory MMP activity may result in:

§ Degradation of newly deposited tissue components

§ Destruction of GFs, cell surface receptors

§ Chronic, non-healing wounds that look like ischemic ulcers

MMP = matrix metalloproteinases.

Why isn’t it healing?

Cortical Erosion

Can it be saved, wound care?

Packed Open with Abx Beads, NPWT, Offloading and Closure

Adequate Wound Care

• Pressure Control • Surgical or Conservative

• Debridement• Infection management• Wound Care• *** Team player

G.S.Schutz, et al., Wound Rep Reg Suppl, 2003;11:1-28

Acute vs Chronic Wounds

Childress BB, et al. Biol Res Nurs. 2002;4(1):5-15.

• Ulcers- 17years• Scleroderma,PAD,DM,InfectionandVenousDisease,Obesity&Depression

• Needadiagnosis,whatisgoingon?• Who’suptobatfirst?

.

SurgicalDebridement

•

• Debridedviacurette,scalpel,andpressurejet•

CombinedTherapyandTeamwork

• Compression,offloading,endovascularprocedure

• Ultrasound+PDGF-BB+NPWT+SkinGraft

PDGF-BB = platelet-derived growth factor-BB; NPWT = negative pressure wound therapy.

Failed skin graft

Acellular Cadaver Skin silver dressing

44YODMmale

PostprocedurePostIVantibiotics+ExcellentSOC

Cryopreservedhumanumbilicalcordpromotesregenerativetissuedisruptstheinflammatorycycle

Retains the Heavy Chain Hyaluronic Acid/Pentraxin3 (HC-HA/PTX3)

New Biologic Treatments

Dressing combination

NO gel secondary layer

NO activating contact dressing

Nitric oxide (NO) is a volatile gas, produced in tissues of the body and acts as a vital cell-to-cell signaling mechanism. The discovery that NO is involved in several critical physiological processes led to a 1998 Nobel Prize.

Anitric oxide generating medical device

DevelopedapeptidemimeticoftheC-terminusofCx43,alphaconnexincarboxy-terminal(ACT1)

§ Cell-Cell communication is a key aspect of injury response

§ Has an important role in skin repair and skin tumor development,

§ aCT1 peptide helps restore gap junctional communication that is compromised after tissue injury

SeveralnewAutologousGraftSystems

Objectives:

Take away:

1. Understand key elements of wound careSurgery, debridement, off loading and advanced

therapies.2. Understand how to incorporate wound

care basic to improve patient outcomes…………………………………………………ü Understand that wound care is never basic

when it comes to CLI patients. ü It requires advanced early care before and

after vascular interventions