1. 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

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

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

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

5. 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 months: % major amputation
With therapy in 12 months: % dead - 25 % major amputation - 50% alive, with limb salvage
SECD, Eur J Vasc Endovasc Surg (1992)

6. 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

10. Becken-Bein-AngioCT

13. 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

14. 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

15. 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

16. Case 1 16

17. Case 1 17

18. Case 2 18

19. Case 2 19

20. Case 2 20

21. Case 2 21

22. Case 2

23. 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

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

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

26. Hydrogel
Improves autolysis
Keeps wound moist
Improves granulation
Secondary dressing necessary

27. Hydrocolloid
minor exsudating wounds
Keeps wound moist
Improves granulation

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

29. Superabsorber
highly exsudating wounds
avoids maceration
primary and secondary dressing

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

31. 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

32. 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.

33. 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.

34. 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

35. 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!

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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.

44. PolyMem® Wic Silver Rope

45. 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