Number 29

CRITICAL LIMB ISCHEMIA SUCCESSFULLY TREATED BY INTERMITTENT PNEUMATIC COMPRESSION

Yoram Moses MD and Boris Yoffe MD, FACS
Department of General Surgery and Vascular Surgery, Barzilai Medical Center, Ashkelon, Israel

IMAJ;Vol 4, Issue 9: September 2002

Intermittent pneumatic compression is a well-known method for the prevention of deep vein thrombosis and reduction of lymphedema in the lower limbs. Recently however, the concept of using IPC for the treatment of ischemic legs reemerged [1]. This method, which applies impulse compression based on high pressure rapid inflation technology, was found to improve arterial ciritical in the loer limbs [2]. We present the case of patient with critical limb ischemia successfully treated by thi method.

Patient Description
A 75 year old man was referred to our outpatient clinic after one year of progressive rest pain in both legs accompanied by edema in his lower legs and non-healing ulcers on his calves. He also suffered from chronic obstructive pulmonary disease and non-insulin diabetes mellitus. Physical examination revealed blood pressure 130/59, plues 90, a systolic hear murmur, absences of pulses in both legs below the groin region, two arterial ulcers on each leg and bilateral edema of the feet. The patient was defined as having critical limb ischemia (Fountein III) and immediate measures were necessary to restore perfusion.

After team consult the patient was considered to be a non-surgical candidate because of the high operative risk. We decided to try the recently introduced IPC device ArtAssist AA-1000e (ACI Medical, In. San Marcos, CA, USA) that has food and calf cuffs (known as IPFCC). A treatment regimen of 3 hours a day in divided sessions was started immediately and the patient continued this mode of therapy for 3 months as an outpatient. We noticed a prominent reduction in his leg edema after 3 days, and the patient felt relief of his rest pain. Three weeks after the treatment was begun the hlcers had healed. Doppler examinations at the end of the 3 months demonstrated a significantly improved ankle-brachial index in both legs compared to the previous Doppler exm [figure], and there was a favorable change in the pulse volume recording. At the end of 3 motnhs there was a subjective and objective improvement in both legs. We were not able to detect any change in the distance walking because the patient's severe COPD prevented prolonged ambulation.

Comment
Recently, external pneumatic compression has been shown to significantly aid in the treatment of peripheral occlusive arterial disease. Claudication range has been at least doubled, along with demonstrated improvements in ankle-brachial index. During the last decadeg, extensive research at several academic vascular centers has investigated the potential of this modality in the management of patients with peripheral occlusive arterial disease. Most of the studies assessed the acute effects of IPC on the circulation [3] and their reports showed positive physiologic and hemodynamic changes as well as clinical improvement. A dramatic increase in both skin perfusion and volmetric arterial blood flow was documented [2]. The mechanism behind these effects suggests an increased arterial-venous pressure gradient due to the drop in venous pressure during compression. Second, the impulse on the endothelial surface lease to release of substances such as nitric oxide causing vasodilation [4] as well as antithrombotic and fibrinolytic effects [5]. In addition, it is postulated that abolitions of the veno-arteriolar reflux - a protective mechanism - causes peripheral vasodilation by reducing the venous pressure.