Dear Editor,
We would like to thank the authors of the letter for their pertinent comments on our manuscript. We fully agree that CLI treatment cannot be accomplished by surgery alone and recognise the importance of postoperative care, including wound management and medication. In our manuscript, we emphasise that healing ischaemic wounds is not easy, even after successful revascularization, because of the impaired wound healing ability and impaired immune system of compromised patients, such as those with diabetes or end-stage renal disease (ESRD).
As mentioned in the manuscript, we employ negative pressure wound therapy (NPWT) for most deep wounds to facilitate granulation formation. NPWT is one of greatest advances in the field of wound management and may contribute to shortened ulcer healing time.
1
Conversely, hyperbaric oxygen therapy (HBO) is not used routinely in our institution because of its inaccessibility. Further randomised studies are required to evaluate whether HBO has benefits even in revascularised feet. To stimulate cell growth and accomplish complete epithelialisation, a recombinant fibroblast growth factor (FGF) spray was applied to most of patient wounds. Although, in this study, more than several months were required to heal ischaemic ulcers in patients with ESRD despite employing NPWT and the FGF spray, new bioengineered technologies for stimulating angiogenesis and new advanced wound healing technologies are expected.2
Currently, there is no clear recommendation for postoperative medication in CLI patients that is supported by strong evidence. A portion of our patients (25%) experienced critically low graft flow as a result of poor run-off. To improve the microcirculation and increase graft flow, those patients underwent a prostaglandin E1 infusion through the vein graft. While all patients were postoperatively administrated antiplatelet agents, cilostazole was selected to 38% of patients to prevent progressive vein graft intimal hyperplasia and life-threatening cardiovascular events.
Further basic and clinical studies are required to examine postoperative standard care and to improve wound healing and the QOL of CLI patients.
References
- Negative pressure wound therapy after partial diabetic foot amputation: a multicenter, randomized controlled trial.Lancet. 2005; 366: 1704-1710
- Wound care: the role of advanced wound healing technologies.J Vasc Surg. 2010; 52: 59S-66S
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Published online: April 30, 2012
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© 2012 European Society for Vascular Surgery. Published by Elsevier Inc.
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- Postoperative Treatment of Critical Limb IschemiaEuropean Journal of Vascular and Endovascular SurgeryVol. 43Issue 6
- PreviewWe congratulate the authors for their study.1 Although the results of this study are quite valuable with a satisfying number of patients, we think that it is essential to define which therapies were employed postoperatively, except angiosome concept. We believe that the treatment of critical limb ischemia (CLI) cannot be accomplished by surgery alone. These patients typically have ulcers in their extremities prior to surgery as well. It is well known that postoperative systemic or specific treatments for these ulcers affect minor and major amputation rates.
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