The Effect of Hyperbarics on Lower Extremity Gangrenous Wounds not Amenable to Revascularization

The Effect of Hyperbarics on Lower Extremity Gangrenous Wounds Not Amendable to Revascularization.

A 71 year old white male underwent coronary artery bypass grafting.  He had vein harvesting of the upper saphenous vein on the right side.  Postoperatively he had significant edema with bulla formation of the bilateral forefeet and eventual gangrene into tendon.  A transcutaneous oxygen measurement was performed showing very low oxygenation levels.  He had an MR angiogram showing small vessel disease.  Based on the MR angiogram, he was not a candidate for revascularization.  There was no target vessel.  The patient was advised that he would need bilateral amputation in time.   Stabilization of the wounds was a tentative goal.  Wound healing was not a realistic goal.

Previous history: Diabetes type II, Peripheral Arterial Disease, Hypertension, chronic venous insufficiency.  Patient on cilostazol.   

Goal:  Promote angiogenesis in a diabetic with gangrenous wounds. 

Past Management: 1 month of elevation and silver sulfadiazine dressings.

Clinical course:  In-chamber TCOM with good results (normal greater than 100) patient 247.  The patient qualified for hyperbaric oxygen therapy under Wagner Grade IV, (documentation of any area of the lower extremity with localized gangrene).  30 treatments were completed and patient showed remarkable, unexpected improvement.  During HBO the patient was seen weekly for removal of non-viable tissue, treatment of infection, and moist wound healing. After 8 weeks, “His granular bed increased by at least 80% and was ready for skin grafting” (vascular surgeon).  Split thickness skin grafts were done and there was 100 % take except over the right great toe which later developed into osteomyelitis and a right ray amputation. The surgical incision dehisced, requiring10 more HBO treatments for a failed flap.  In conjunction with HBO we used bioengineered tissue for complete healing and limb salvage.  Wounds healed in 13 months.

Conclusion:  Hyperbarics helped save these limbs.