Oscar M. Alvarez, PhD, Martin Wendelken, DPM, RN, Lee Markowitz, DPM, Christopher Comfort, MD
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1 EFFECTIVENESS OF INTERMITTENT, PNEUMATIC COMPRESSION FOR THE TREATMENT OF VENOUS ULCERS IN SUBJECTS WITH CHRONIC (SECONDARY) LYMPHEDEMA Results of A Prospective Randomized Clinical Trial Oscar M. Alvarez, PhD, Martin Wendelken, DPM, RN, Lee Markowitz, DPM, Christopher Comfort, MD Center for Curative and Palliative Wound Care Calvary Hospital, Bronx, NY Department of Medicine New York Medical College Valhala, NY
2 Secondary Lymphedema Caused by: an inadequate lymphatic drainage system due to constriction obliteration from: Surgery Radiation Trauma Untreated CVI Infections Can develop immediately post operatively, or weeks, months or even 10 to 20 years later
3 Lymphedema Accumulation of lymph in the interstitial spaces Caused by a defect to lymphatic system Abnormal collection of excess tissue proteins Edema Chronic inflammation Fibrosis Bacterial & Viral infections Cutaneous Manifestations
4 Diagnostic Features Swollen feet Deep creases at joints Square toe Shovel toe Stemmer s sign
5 Untreated Lymphedema Tissue channels to increase in size and number Reduction of oxygen through the transport system Interference with wound healing A culture medium for bacteria and virus that can result in various infections Fibrosis (hardening) of the extremity tissue in chronic inflammatory conditions
6 Treatment Options Medications Antibiotics, diuretics, anticoagulants, pantothenic acid, pyridoxine, hyaluronidase no proven therapeutic value Surgery Debulking, microsurgical resection, liposuction do not improve lymph flow many complications Complete Decongestive Therapy (CDT) Treatment of choice
7 Study Design Prospective Randomized One Center Open Label Controlled v. Std Care Run in phase 32 Week duration Primary endpoint Rate of Wound Healing Pain Relief Incidence of Infections Secondary endpoints Edema control QOL
8 Goals of Treatment Pain, exudate, odor control Wound Healing Soften subcutaneous tissue Prevent infection Decrease limb size Increase patient function Weight loss
9 Inclusion Criteria Hard to Heal Venous Ulcers Lower leg ulcer due to CVI Ulcer size >20 cm2 Ulcer history >1yr Non Responders (Failed healing with compression alone) Pain index >6
10 B O ig LD Wound
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12
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14 Exclusion Criteria Ulcer of non venous etiology ABI <0.75 Wound Infection Current use of systemic corticosteroids Chemo or radio therapy Subject is presently confined to bed or chair Participation in another clinical study
15 Statistical Design Intent to treat Wound Pain, Leg edema (Fisher s exact test) Time to healing & relative rate of healing (Kaplan Meier & log rank chi square test)
16 Treatments IPC plus Compression 4LB* applied twice weekly IPC therapy for 1h bid Compression alone 4LB* applied twice weekly *Profore, Smith & Nephew, Largo, FL
17 Compression Bandages were applied once weekly at the clinic and once weekly by a visiting nurse. Bandaging was only performed by trained professionals
18 Test Agent* 4 Chamber, gradient, sequential, pneumatic Short Sleeve (19 ) 3/4 Sleeve (31 ) 1 hour bid (morning & evening) Pre set and locked at 50 mmhg Therapy sessions in the decubitus position Daily diaries IPC devices checked every 4 weeks Subject / family in service provided
19
20 PDP Software (PictZarTM) Length Area Circumference Width
21 Wounds were measured using digital photograph planimetry* * PicZar BioVisual Technologies, LLC
22 Median Time to Wound Closure by 8 Months (N=52) Time (Days) P=0.059 P=0.047 P= LB N=27 IPC+4LB N=25 Wound Closure
23 04/26/05 05/11/05
24 VAS Wound Pain Scores * * * *P<0.05
25 Rate of Healing Treatment 4LB 4LB plus IPC Rate of Closure mm/day ±SEM P value 1.1 ± ± N 25 27
26 Leg Edema Ankle & Calf Circumference Group Baseline Ankle/Calf (cm) Week 20 Ankle/Calf (cm) % Δ Ankle/Calf (cm) IPC plus 4LB 46.5/ / /18.7 4LB (Control) 44.7/ / /12.7
27 EDEMA
28 Conclusions The median time to healing by 8 months was 135 days for the IPC treated group and 198 days for the control group (p=0.039) The rate of healing was 1.1 mm/day for the control group and 2.3 mm/day for the group treated with IPC (p=0.026) Compared to subjects treated with compression alone, the group treated with IPC reported less pain at each evaluation point for the first 6 weeks. The IPC treated group had greater reduction in leg edema (18% vs 12%)
29 Funded By New York State Department of Health and Human Services Cairo Foundation, Valley Stream, NY IPC 2004 Circulators were generously provided by Bio Compression Inc., Moonachie, NJ
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