The role of Vascular Surgery and wound care treatment Dr. W. Amann Division of General- and Vascular Surgery LKH Villach, Austria XV. Educational seminar for doctors; Nov. 11, 2011 University Medical Center ( UMC ), Ljubljana

Chronic wound and vascular disease majority of patients in vascular medical units majority of hospital stay days cost intensive

Etiology of chronic wounds ( crural ulcers ) combined venous and arterial 70 % arterial ( atherosclerosis ) 20 % diabetic 5 % traumatic 3-4 % vasculitis 1 % neoplastic <1 %

Management of chronic wounds Diagnosis of vascular disease Causal treatment Local treatment

Chronic critical ischemia Stage I Asymptomatic, decreased pulses, ABI < 0.9 Stage II Intermittent claudication Stage III Daily rest pain Stage IV Focal tissue necrosis Fontaine stage III and IV prognosis Without therapy in 6 - 12 months: - 90 % major amputation With therapy in 12 months: - 25 % dead - 25 % major amputation - 50% alive, with limb salvage SECD, Eur J Vasc Endovasc Surg (1992)

Diagnostic algorithm for PAOD 1. Clinical examination 2. Pulse status 3. Ankle brachial index 4. Acral oscillography 5. Treadmill 6. Tcpo2 7. Duplex - ultrasound 8. Angiography Weitz JI et al. Circulation 1996;94:3026–3049

Becken-Bein-AngioCT

Causal treatment of vascular disease Desobliteration - Interventional ( Angioplasty ) - Surgical ( bypass surgery ) Medical vasoactive treatment - Prostanoids Combination Lumbal or thoracal sympathectomy Last option : SCS – spinal cord stimulation

Local treatment – mandatory factors Debridement ( surgical, autolytic, biological ) Moisture Wound temperature Prevent and/or treat local infection Exudate management Pain reduction Easy handling ( outpatient ) Cost effective

TIME - principles of wound bed preparation Tissue revascularization removal of non-viable or deficient tissue Infection control of infection or inflammation local antiseptic systemic antibiotics Moisture Exsudate management Edge of wound excavation hyperceratosis maceration epitheliasation

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Local wound therapy - dressings A lot of different dressings available A lot of confusion which one to take according to wound situation Costs ? Low evidence of what is the best

Povidone iodine infected wound easy to handle cheap potential cytotoxic Iodine allergic patients Needs secondary dressing

Alginates with/without silver Infected wounds Keeps wound moist Improves granulation good for excavates wounds Secondary dressing necessary Higher costs than iodine

Hydrogel Improves autolysis Keeps wound moist Improves granulation Secondary dressing necessary

Hydrocolloid minor exsudating wounds Keeps wound moist Improves granulation

Foams – polyurethane Moderate exsudating wound Keeps wound moist sometimes adheres to wound bed painful dressing change alterates wound bed

Superabsorber highly exsudating wounds avoids maceration primary and secondary dressing

VAC – vaccuum assisted closure large excavated wounds Good exsudate control improves granulation expensive difficult for outpatient

Summary conventional wound dressings Dressings have different characteristics Use of many different dressings in each phase of wound healing process is possible Need for high expertise to choose the best one in a certain situation Need for different combinations increases costs

PolyMem® Multifunctional dressings These multifunctional dressings promote: Gentle autolytic debridement Rapid debriding and wound healing results Reduction of pain and inflammation around the wound Non-adherence of dressings to the wound bed Quick, simple and pain-free dressing changes Might look and feel like foam dressings but due their composition they have an entirely different mode of action.

PolyMem® Multifunctional dressings All PolyMem dressings have the same core technology Hydrophilic Polyurethane (carrier) Wound cleanser - F-68 Surfactant Moisturizer – Glycerin Superabsorbent ( Copolymer ) absorbs fluids 10 ( Polymem ) to 16 fold ( Polymax ) of own weight Semi-permeable backing film ( not on cavity products) Application of PolyMem on wound, wound fluid is immediately absorbed into the dressing. Wound fluid absorbed into the dressing making it swell and fill the wound contours. Release of wound-cleanser and glycerine onto the wound bed. Surfactant and glycerine stimulate autolytic debridement. Exudate retained in the dressing due to superabsorbents.

PolyMem ® Silver ™ All the advantages of PolyMem dressings, plus the antimicrobial benefits of silver! In vitro testing demonstrates kill of at least 99.9% of all bacteria and fungi populations* Nano-crystalline silver particles are equally distributed throughout and bound into the membrane. Unlike other silver dressings - Non cytotoxic! No skin staining *Organisms tested – Klebsiella pneumoniae, Staphylococcus aureus, Pseudominas aeruginosa, Enterococcus faecalis, Staphylococcus aureus, Candid albicans

Example of effect after 24 hours 24/7 Example of effect after 24 hours Stagnating (4 months) wound on tibia after trauma. PolyMem has reduced the hypergranulation, odour and pain in only 24 hours. Note the clean wound surface and absence of the slimey film and slough that had previously covered the wound. 25/7 No need for additional cleansing!

How does PolyMem reduce pain? Inhibits the actions of the pain-sensing nerve endings under the dressings*. (“nociceptors”) These same nerves, when activated, create the series of events that result in; - bruising - swelling - edema - pain. Evidence suggests that the dressing might absorb sodium ions, by capillary action, from the skin and from the subcutaneous tissues. If this is true, then this local decrease in sodium ions would result in reduced nociceptor nerve conduction, which could account for the observed pain relief. Inflammation

An incisional study on a rodent model The coming slide demonstrates how PolyMem reduces the spread of inflammation (and pain which is linked to inflammation) in the tissue surrounding the trauma (in this case, inscisions/cuts) The inscisions on the animals were either: - left uncovered - covered with gauze (earlier study showed same result with gauze and a placebo foam) - covered with PolyMem Following slide show histological photos of the inflammatory reaction of surrounding tissue. Note that there is no reduction in the robust localized inflammatory response required for healing the injury!20 Suppression of the spread of the inflammation and swelling cascade into the surrounding, uninjured tissues helps accelerate the healing process. 16,20 Photos courtesy of Dr. Alvin J. Beitz, University of Minnesota

An incisional study on a rodent model The vertical lines measure the extent of the inflammation, which is dramatically more localized with Polymem®. Note that there is no reduction in the robust localized inflammatory response required for healing the injury!20 Suppression of the spread of the inflammation and swelling cascade into the surrounding, uninjured tissues helps accelerate the healing process. 16,20 Photos courtesy of Dr. Alvin J. Beitz, University of Minnesota

Blunt trauma animal model Uniform blunt trauma to both legs on 14 anesthetized animals PolyMem® dressing plus a compression wrap applied to one leg Only the compression wrap was applied to the other leg Two independent observers evaluated swelling (0 – 4 scale) PMD + wrap wrap PMD+wrap wrap Data courtesy of Dr. Alan R. Kahn, University of Minnesota

Charcot foot treated with PolyMem® 4,5 months to closure with PolyMem Silver WIC + PolyMem (without silver). The wound was NOT debrided or cleansed in-between dressing changes. Poster presented at EWMA 2008

Heel ulcer 1. treated with PolyMem® 3 months to closure with PolyMem Silver WIC + PolyMem. The wound was NOT debrided or cleansed in-between dressing changes. Poster presented at EWMA 2008

Heel ulcer 2. treated with PolyMem® 8 months to closure with PolyMem + PolyMem WIC. The wound was NOT debrided or cleansed in-between dressing changes. Poster presented at EPUAP 2009

PolyMem® Wic Silver Rope Main indication is tunneling wounds/fistulas Reinforced with a surgical mesh (top and bottom) Can be cut in half lengthwise (use slits as guide) Absorbs up to 6x its own weight (will swell up to 1/3) One piece removal.

PolyMem® Wic Silver Rope

Local treatment – summary Optimum: one product for all options Monotherapy Factors for cost effectiveness price nursing time need for hospital stay need for additional treatment ( pain, cleansing etc ) storage costs healing time First line local treatment