Paul S. van Bemmelen, MD, PhD |
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A recently published study In the Journal of Vascular Surgery1 has surprisingly shown that medical treatment using ArtAssist2 pump technology now provides excellent limb salvage for ischemic foot ulcers in limbs not amenable to surgical revascularization. The 94% limb salvage rate included diabetics with multilevel vessel involvement. Our own experience with the home use ArtAssist device has been extremely encouraging and is typified with the following case:
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66-year-old man with a 35-year history of diabetes (NIDDM) and chronic renal failure (peritoneal dialysis) presented with dry necrosis of his right great toe. He ambulated very little outside of his home and he had previously undergone a tibial bypass of the opposite leg. He was being treated with platelet released growth factors for poor healing of his left distal ankle incision. Ankle blood pressure was not obtainable due to non-compressibility, but wave forms were consistent with disease of the small vessels distal to the knee. The metatarsal pulse volume recording is shown and is essentially flat. Toe-pressure was in the ischemic range.
The patient underwent repeated selective digital intra-arterial angiography, which demonstrated patent arteries to the level of the ankle only, without named run-off vessels in the foot. After explaining the poor chances of healing a toe amputation to the patient, he underwent amputation of the right great toe and metatarsal head since treatment with the ArtAssist device was not available at the time. The toe amputation failed and complete dehiscence, with exposed metatarsal bone was apparent.
Debridements and immediate treatment with growth factors were instituted. Further deterioration occurred slowly. Further revision foot amputation was not considered to be a worthwhile option and below-knee amputation would be the next surgical step.
Intermittent compression with the ArtAssist device was started two months after the toe amputation for at least 30 minutes, QID. Compression was well tolerated and after one week of home treatment, the patient noticed blood on all his dressings. Slowly, some granulation tissue appeared and the wound edges bled well with minor debridements. Improvement of the metatarsal pulse volume recording was noted. In view of the exposed metatarsal bone, with retracted skin edges, a further resection of metatarsal I and the adjacent second toe was performed after two months of compression therapy. Oral antibiotics were given based on culture results. The growth factor treatment was stopped. The resulting wound is now healed by secondary intention. Further improvements occurred in the pulse volume recording at the metatarsal level, to the same amplitude as the bypassed side.
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Figure 1: Before ArtAssist Pump Treatment |
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Figure 2: After 2 Months of Treatment |
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Figure 3: After 2 Months of Treatment |
Other published studies support the understanding that the permanent improvements seen with this device are attributable to arteriogenesis, the opening of collateral arteries that form a natural bypass around the obstructed arteries.
The ArtAssist device is to be prescribed for a three month period to allow adequate time for arteriogenesis to occur.
VA podiatrists enter the consult which includes: “ArtAssist pump for 1 hour, 3 times a day for 3 months, contact Dana Lockrey at 951-852-3384.” The manufacturer then works directly with patients for timely delivery, ensuring proper use and pick up when therapy is complete.
The manufacturer, ACI Medical, will be providing live demonstrations of increased skin perfusion using the ArtAssist pump at the upcoming Desert Foot meeting in Phoenix, November 16-18.
