Compression Therapy Could Decrease Pain for "No-Option‚" CLI Patients

In the July issue of Vascular Disease Management, the article by Kavanagh et al describes the use of sequential pneumatic compression (SPC) in the treatment of critical limb ischemia patients deemed to have no option for successful revascularization. I will begin by stating that the definition of “no options” for revascularization varies profoundly between practitioners throughout the world. Despite this, there are clearly some cases in every practitioner’s experience where adequate revascularization simply can’t be achieved. This group of patients suffers from severe pain and poor quality of life. They have dismal long-term survival. Any therapy that can alleviate pain and improve limb salvage in these cases warrants careful attention. In addition to the effects in “no-therapeutic-option patients,” one must also wonder if these treatments would have benefit as adjunctive therapies in patients who have successful revascularization, because long-term patency rates are not ideal.

In this study, patients treated with 6 hours to 8 hours of sequential pneumatic compression per day for 12 weeks showed substantial early and long-term benefit, particularly in pain relief. There seemed also to be benefit in amputation-free survival and overall mortality as compared to primary amputation. Remarkably, those patients who obtained the device for longer-term use had more symptomatic relief but didn’t seem to have a statistically significant decrease in amputation rate than the group that received therapy for 12 weeks only. The cost of therapy was dramatically less than primary amputation.

Dr. Sultan and colleagues provide an extensive review of the possible mechanisms by which sequential pneumatic compression may portend benefit, including augmented venous emptying which creates an increased arterial-venous pressure gradient, increased production of nitric oxide, and angiogenesis. Marked increase in popliteal arterial flow was noted during the study. Although this is not a randomized controlled trial, these data are encouraging and warrant further evaluation.

As the incidence of critical limb ischemia is growing rapidly, practitioners are developing better revascularization techniques. Unfortunately, revascularization is not universally successful on a short- or long-term basis. Systolic pneumatic compression coupled with optimal medical therapy may have the potential to improve overall mortality, increase amputation-free survival, and dramatically reduce costs compared to an amputation-first strategy. Despite the need to utilize these devices for 6 hours to 8 hours on a daily basis, patients complied with therapy and noted improved quality of life. This method of treatment may represent an important tool in our armamentarium to more effectively treat those patients who present with critical limb ischemia.