Pioneering Non-Invasive Vascular Technologies Since 1984

Endothelial Activation is Central to Collateral Artery Growth in PAD Patients

Collateral artery growth is possible for patients with critical limb ischemia with the use of external pneumatic compression therapy. Many vascular specialists are skeptical of this notion because it sounds contradictory:  how can a completely non-invasive treatment improve microvascular circulation to the point that the limb is saved?

Efficacy lies in the activation of the endothelium by way of exerting shear stress on the vessel.

Vascular specialists have good reason to be wary of most compression pumps claiming to promote better circulation and limb salvage. This is because the developers of such pumps did not design their systems with the endothelium in mind, preferring instead to modify lymphedema pumps or DVT prophylaxes to exert more pressure on the patient’s limb at slow compression and decompression rates (two or more seconds). Little clinical evidence exists to support this technique and little thought was put into this type of system’s design for arterial disease treatment. Furthermore, with such compression pumps, little or no pressure is applied to the foot or watershed areas, limiting cutaneous blood flow in these regions.

Now, for the endothelium. When shear stress is exerted on a vessel, its inner lining naturally secretes vasodilators and anticoagulants such as nitric oxide and TcPO2. In effect, the vessel temporarily widens, allowing more inflow. This effect can only be achieved with rapid external compression and decompression (each less than 0.5 seconds). Over time, the daily application of shear stress will encourage the growth of existing collateral arteries, as seen below:

angiogram van bemmelen artassist arterial pump technology

Arteriogenesis (or collateralization/collateral artery growth) explains why patients have long-term results after stopping ArtAssist® device usage

The ArtAssist® device is the only external pneumatic compression pump designed to focus on collateral artery growth. It activates the endothelium with rapid compression and decompression rates in the foot, ankle, and calf regions. This addresses poor circulation and wounds present from heel to toe, as well as in the rest of the limb.

Acquiring an ArtAssist® device is simple and may be reimbursed by insurance in certain areas of the United States. Device technology experts can discuss medical benefits with both physicians and patients, and will also fulfill orders. Call or email ACI Medical to begin:  toll free (888) 453-4356 or info@acimedical.com.

ArtAssist Device collateral artery growth

The ArtAssist® device is available in the US and internationally.

 

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“Rapid” compression technique to treat PAD

Rapid Compression:  How Fast is Fast Enough?

Compression pump systems for peripheral arterial disease treatment and wound care are becoming more and more popular these days. As more people seek treatment for conditions caused by poor circulation, the number of cases contraindicated for surgical intervention also rises. So, to find an alternative to amputation, some medical device makers are advertising their pumps as a solution.

In general, here’s what you’ll see:

  • Cuffs/sleeves:  can cover the foot & calf or just the calf
  • Pressure:  90 – 120 mmHg

Here’s a secret, though:  most of these “arterial pumps” are nothing but DVT prophylaxes or lymphedema pumps that are modified to exert more pressure. Minor adjustments such as these have been largely untested in a clinical setting and therefore yield fairly unpredictable results.

ACI Medical is the only device maker to have uncovered the most important aspect of compression therapy as a means of treating PAD:  rapid compression (under 0.5 seconds) that serves as a close physiological substitute for brisk walking.

ArtAssist device compression sequence

Unlike all other compression pumps, ACI Medical’s ArtAssist® Arterial Assist Device® was engineered on the premise of understanding the underlying physiology of increasing arterial blood flow and focusing on results that will benefit patients with critical limb ischemia. Since developers and researchers understood how important exercise was for patients with arterial disease, they engineered a device that would bring the important physiological benefits of walking to patients with limited mobility.

Early physiological studies led by Dr. Paul van Bemmelen, Professor Andrew Nicolaides, and others showed a great understanding of the vascular system of the legs. When we exercise, our calf muscles push blood rapidly through the veins to the heart where it can be recycled and directed back towards the leg muscles with essential nutrients. Therefore, in patients who have difficulty walking, it was essential to emulate the calf muscle’s role in pumping blood without having the patient do exercise.

So, when a patient uses the ArtAssist® device, it is as if the device system is “walking” for them. Patients do not experience pain and, over a period of about three months, benefits become long-term.

The real experts on Arterial Pump Technology are only a click or call away. Email info@acimedical.com or call toll free (888) 4 LEG FLO

Relevant clinical trials using the ArtAssist® device:

Rapid Intermittent Compression Increases Skin Circulation in Chronically Ischemic Legs with Infra-popliteal Arterial Obstruction.
van Bemmelen, P.S.; Weiss-Olmanni, J. and Ricotta, J.J. Div. of Vascular Surgery, State University of New York, Stony Brook.
VASA 2000;29:47-52

The Contributions of Arterial and Venous Volumes to Increased Cutaneous Blood Flow During Leg Compression. Eze, A.R.; Cisek, P.L.; Holland, B.S.; Comerota, A.J. Jr.; Veeramasuneni, R.; and Comerota, A.J. Philadephia, Pennsylvania, Charlotte and Gastonia, North Carolina. Annals of Vascular Surgery, 1998;12:182-186

Effects of Intermittent Pneumatic Compression of the Calf and Thigh on Arterial Calf Inflow: A Study of Normals, Claudicants, and Grafted Arteriopaths. Delis, K.T.; Husmann, J.W.; Cheshire, N.J.; and Nicolaides, A.N. Imperial College School of Medicine, St. Mary’s Hospital, London, UK. Surgery, 2000, Vol. 129, No. 2, p. 188-195

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A modified DVT pump for treating arterial disease? Don’t waste your time.

These days, intermittent pneumatic compression therapy is being used to treat edema, prevent deep vein thrombosis, and, more recently, similar devices have emerged claiming to treat peripheral arterial disease, a serious result of poor circulation in the limbs.

Some device manufacturers will tell you, “Hey, this pump that we use to prevent DVT and reduce edema can ALSO be used to treat arterial disease if you just kick the pressure up a notch.” Or at least they think so. It’s still a compression pump, right? And this DVT/edema/arterial pump will kill two birds with one stone, right? So why not?

unequal

The biomedical engineers here at ACI Medical and the vascular surgeons they work with can set this straight:  the simple answer is that, since arterial disease and venous disease are inherently different, they should be treated differently.

The companies that just modify lymphedema and DVT pumps and claim these systems can prevent amputations caused by peripheral arterial disease do so without much evidence to back them up. Do their pumps work? Maybe. Is that good enough? Come on.

The team that developed ArtAssist®…the Arterial Assist Device® for ACI Medical approached the arterial pump concept very differently. They realized early on that the new concept of treating peripheral arterial occlusive disease with non-invasive arterial pump compression therapy deserved a lot more thought. With that, they started from scratch and set these goals:

Understand the underlying physiology of increasing arterial blood flowThe ArtAssist Arterial Pump Device

Design a device based on this understanding

Determine the long-term clinical benefit(s) to patients with critical limb ischemia

Starting in the early 1990’s, ACI Medical’s team of biomedical engineers and vascular surgeons began a thorough progression of research and clinical trials that started with incorporating their most promising findings into the design and function of the ArtAssist® device.

Today, doctors from all around the country (and even some in other countries) prescribe this optimized arterial pump to their non-operable PAD patients because they know how critical it is for threatened limbs to receive optimized therapy that’s been proven to work again and again.

So it’s time for me to put up or shut up – view study abstracts on the ArtAssist® device at this link:

http://acimedical.com/artassist/clinical-studies/

My suggestion:  start with the History and Literature Review and our Scientific Brochure.

Then, call ACI Medical at our toll free number (888) 453-4356 or email Don, our Director of Sales & Marketing, at info@acimedical.com to talk to a real, live expert.

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“Walking Therapy and Pneumatic Compression: The Natural Cures for Poor Leg Circulation” | Paul van Bemmelen, MD, PhD, FACS

paul van bemmelen md phdYou’ve already seen Dr. Steven Kavros’ article on pneumatic compression device therapy published on faim.org (the Foundation for Alternative and Integrative Medicine).

But just released is yet another article on pneumatic compression therapy with an emphasis on its natural approach to healing non-reconstructable PAD (peripheral arterial disease) patients. This time, FAIM.org is featuring Dr. Paul van Bemmelen, one of the very few vascular surgeons who have conducted the most advanced investigations into the capabilities of arterial pump technology for non-surgical patients with poor leg circulation.

Here is an excerpt from Dr. van Bemmelen’s latest article:

“Because healthcare providers are paid much more for invasive procedures, our healthcare system currently favors costly procedures as the primary solution for circulation problems. In Ireland, a study on 171 patients treated with the compression device, found a savings of about 1.5 million Euros compared to cost of amputation for a matched group of patients.”

In addition, this article gives insight into the origins of compression therapy and why previous attempts at treating PAD with with it had been largely unsuccessful prior to the development of the ArtAssist® device, technology to which Dr. van Bemmelen himself contributed a significant amount of his vascular expertise.

ArtAssist® Arterial Pump Technology is the pioneer for non-invasive intermittent pneumatic compression therapy. By mimicking the benefits of the most natural way of fighting arterial disease, this treatment is proven to provide long-term relief for patients suffering from poor circulation.

Look for the full article on faim.org!

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Using a Pneumatic Compression Device for Lower and Upper Extremity Peripheral Arterial Disease | FAIM.org

ArtAssist pneumatic compression device

ArtAssist®…The Arterial Assist Device®

by Steven Kavros, DPM

Intermittent pneumatic compression (IPC) of the lower limb is a well-documented method of arterial leg inflow enhancement in patients with peripheral arterial disease (PAD). The mechanism of action parallels the natural muscular contraction of the leg stimulating blood flow. There are three very short compression cycle per minute inflating a cuff encompassing the legs and or feet simulating the beneficial effects of walking. The rapid rise of the cuff pressure assists with emptying of the venous blood of the extremities and allows oxygenated blood to move down the limb delivering nutrients to deprived tissues. This simple mechanism of action also allows edema or swelling of the extremity to be relieved. By relieving swelling, additional oxygenated blood can be delivered to the ischemic limb. Additionally, there is an increase release of nitric oxide and certain tissue and platelet derived growth factors. The nitric oxide has a positive effect on the internal cells that line the vessel wall, enabling relaxation and improved flow. Other tissue and growth factors lead to the development of new blood vessels and therefore, improve the delivery of additional oxygen and nutrients to the extremity.

Read the rest via Using a Pneumatic Compression Device for Lower and Upper Extremity Peripheral Arterial Disease | Foundation for Alternative and Integrative Medicine.

Since the Internet is all about getting info quickly and moving on, here’s what this medical jargon means in plain English…

Dr. Kavros is talking about a leg pump (what we’ll refer to as an arterial pump) that is proven to improve circulation to the legs and feet when the arteries are blocked. When your arteries are significantly blocked, your muscles start sending pain signals to your brain. This is called PAD –  think of it as a heart attack of the legs.

The way this arterial pump technology works is by simulating walking for your blood-deprived muscles. Instead of making you get up and walk, this therapy happens while you’re sitting in a chair. When you walk, blood in the veins travels up to your heart, gets refreshed and loaded with oxygen/nutrients, and then comes back down to feed the starving muscles. The better circulation you have in your legs, the less they will hurt.

Dr. Kavros says that this compression sequence can also reduce swelling. This pump compresses your leg three times per minute. If you use the pump for three hours a day, imagine how much more blood flow you’re getting!

A fringe benefit to this therapy that was recently discovered is your body’s natural release of nitric oxide. This substance is not to be confused with nitrous oxide, which is what your dentist will give you to make you laugh at his dumb jokes while he’s working on your teeth. When nitric oxide is released by the lining of your arteries, your blood vessels temporarily open up to accept more nutritious blood. Again, this happens three times a minute so that your blood vessels are constantly widened throughout therapy.

This is the compression technology Dr. Kavros is talking about:  The ArtAssist® device. To learn more, click the picture!

Update:  Dr. Paul van Bemmelen has also written an article for faim.org about pneumatic compression device therapy for PAD. Read it here

ArtAssist pneumatic compression device

ArtAssist®…The Arterial Assist Device®

 

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The ArtAssist® device presented by Dr. Sherif Sultan of the Western Vascular Institute

Dr. Sultan is a consultant vascular and endovascular surgeon who has been studying the ArtAssist® device in a clinical setting at his practice in Galway, Ireland.

An excerpt from his presentation at the 2009 Veith Symposium in New York (note that this is before the final results of this ongoing study were released):

Art-Assist SCBD is a valuable tool in the armamentarium for dealing with CLI patients with un-reconstructable PVD. It gives superior limb salvage, ameliorates amputation free survival, enhances ulcer healing rates, reduces length of hospital stay and provides rapid relief of rest pain without any intervention in patients with limited life expectancy.

http://www.veithsymposium.org/pdf/vei/2852.pdf

artassist compression sequence device

On a related note, Dr. Sultan’s website features a short video about the ArtAssist® device.

For those in Ireland, the ArtAssist® device is distributed by Deprimo, Ltd. (http://deprimo.ie/)

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Compressing the foot and why it’s so important

Why calf-only arterial pumps are missing out

ArtAssist device compression sequence

ArtAssist®…The Arterial Assist Device® Compression Sequence

Calf-only arterial pumps are missing a key component because foot compression is essential to improving circulation in the skin of the foot. Good circulation is vital to the successful healing wounds and ulcers. ACI Medical’s ArtAssist® device went through numerous clinical trials in order to optimize compression therapy for treating peripheral arterial disease of the legs and feet.

Researchers and engineers optimizing the ArtAssist® device not only discovered the importance of compressing the foot in addition to the calf, but they also designed this arterial pump technology to imitate the physiological act of walking as closely as possible.

A bit of background

An early study to determine the physiological effects of  intermittent pneumatic compression therapy focused compression on the calf, foot, and both simultaneously.

Although significant increase in arterial blood flow was recorded for individual compression areas, the simultaneous combination yielded disappointing results because blood was not flowing back to the heart as anticipated.

After the conclusion was drawn that simultaneous compression did not produce the desired augmented blood flow for all tissues below the knee, researchers realized that the answer lay in a time delay. Strong, encompassing foot and ankle compression that boosts foot skin perfusion would come first, followed then by calf compression to amplify popliteal flow.

That magical formulation

In essence, foot/ankle compression + calf compression with time delay = successful emptying of venous blood, resulting in improved circulation.

The optimization study led by K. T. Delis, et. al. determined that this foot, ankle and calf compression sequence, applying 120-140 mmHg at a frequency of 3-4 impulses per minute, “provided the optimum intermittent pneumatic stimulus.”

The next logical step was a prospective randomized controlled trial to solidify the efficacy claims.

And the rest is history…

One example of such a trial studied not only the effects of the previously mentioned IPC method, but also the long-term effects on treated claudicants. The results indicated that treated claudicants still retained their ABI’s and walking benefits one year after the end of IPC application.

Following the numerous physiological and optimization studies for the ArtAssist® device, research facilities continued to explore the possibilities of arteriogenesis, therapy for patients with intermittent claudication, and limb salvage.

The ArtAssist® device is currently the only IPC device with this thorough progression of clinical studies and randomized controlled trials to support its efficacy.

References

  1. Improving Popliteal Artery Flow with Intermittent Pneumatic Foot and Calf Compression.” Delis, K.; Labropoulos, N.; Nicolaides, A.N.; Stansby, G.; and Lumley, J. Irvine Laboratory for Cardiovascular Investigation and Research, Academic Surgical Unit, Imperial College School of Medicine, St. Mary’s Hospital, London, UK.
  2. Enhancing Venous Outflow in the Lower Limb with Intermittent Pneumatic Compression. A Comparative Haemodynamic Analysis on the Effect of Foot vs. Calf vs. Foot and Calf Compression.” Delis, K.T.; Slimani, G.; Hafez, H.M. and Nicolaides, A.N. Irvine Lab for Cardiovascular Investigation and Research, Academic Vascular Unit, Imperial College School of Medicine, St. Mary’s Hospital, London UK. Eur J Vasc Endovasc Surg 19, 250-260; 2000
  3. The Acute Effects of Intermittent Pneumatic Foot and Calf Compression on Popliteal Artery Hemodynamics: A Comparative Study.” Delis, K.T.; Nicolaides, A.N.; Labropoulos, N.; and Stansby, G. Imperial College School of Medicine, St. Mary’s Hospital, London, UK. J Vasc Surg, 2000; 32: 284-92
  4. Intermittent Calf and Foot Compression Increases Lower Extremity Blood Flow.” Eze, A.R.; Comerota, A.J.; Cisek, P.L.; Holland, B.S.; Kerr, R.P.; Veeramasuneni, R.; Comerota, A.J. Jr. Presented at the 24th Annual meeting of the Society for Clinical Vascular Surgery; March 1996. Am J Surg 1996; 172:130-135
  5. Optimum Intermittent Pneumatic Compression Stimulus for Lower-limb Venous Emptying.” Delis, K.T.; Azizi, A.A.; Stevens, R.J.G.; Wolfe, J.H.N.; Nicolaides, A.N. Eur J Vasc Endovasc Surg 19, 261-269 (2000).
  6. Improvement in Walking Ability, Ankle Pressure Indices and Quality of Life in Vascular Claudication Using Intermittent Pneumatic Foot and Calf Compression; A Prospective Randomized Controlled Trial with 1 Year Follow-up.” Delis, K.T.; Nicolaides, A.N.; Cheshire, N.J.W.; and Wolfe, J.H.N. Academic Vascular Surgery, St. Mary’s Hospital, London, UK. Presented at the Vascular Surgical Society of Great Britain & Ireland, Nov. 2000, London Arena.
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Challenge conventions. You may end up saving a limb!

Previously, I posted a whole article about how it’s actually not dangerous to use compression therapy on an ischemic limb. However, that’s not the only misconception that we’ve cleared up at ACI Medical. This article exposes a couple more myths that have been known to float around, and how we’ve found evidence to set the record straight.

Even after some experts dismissed the idea of intermittent pneumatic compression (IPC) as a viable treatment for patients with PAD, the creators and developers of the ArtAssist® device put their theories to the test nonetheless.

Pioneered and developed with vascular surgeons, the ArtAssist® device continues to be the leader in IPC therapy for non-surgical PAD patients with varying levels of severity.

ArtAssist® IPC therapy should not be overlooked or dismissed without having considered the clinical evidence:

in fact, it has both saved limbs and improved patient quality of life.

MYTH: Critically ischemic limbs are maximally vasodilated.

False.

In fact, the ArtAssist® device’s first physiological clinical trial disproves this myth. Even without having been optimized to the extent it is now, the prototype yielded results that suggested transient vasodilation.

Later, in 2005, a study conducted by Professor Labropoulos of SUNY not only confirms the earlier findings, but also suggests that increasing the arteriovenous pressure gradient with foot & calf IPC therapy contributes greatly to significantly increased blood flow in the subjects’ popliteal, gastrocnemial and collateral arteries. Skin blood flow also improved significantly in their findings.

MYTH: The ArtAssist® device is the same as any other arterial pump with similar function.

False.

We encourage you to ask yourself these two important questions when considering other devices which claim to perform as efficaciously as the ArtAssist® device:

1. Is it optimized for arterial disease? And

2. Is there clinical evidence and support for this specific device?

Only the ArtAssist® device satisfies each of these questions with its thorough progression of clinical studies: this device alone has been adjusted and optimized from its initial prototype over the past two decades to effectively treat even the most severe cases of PAD.

  • Physiological
  • Optimization
  • Intermittent Claudication
  • Limb Salvage
  • Critical Limb Ischemia (CLI)
  • Arteriogenesis (Collateralization)

Currently, studies are being conducted to explore the ArtAssist® device’s efficacy for adjunct therapies, such as stem cell treatment and gene expression.

The Bottom Line.

Your patient’s non-reconstructable limb will not wait for hearsay on this form of therapy.

We are here to let you know that therapy with the ArtAssist® device gives patients a dependable option that continues to help non-surgical limbs across the country.

Make the decision that could save your patient from amputation.

References

Augmentation of blood flow in limbs with occlusive arterial disease by intermittent calf compression. Van Bemmelen, P.S.; Mattos, M.A.; Faught, W.E.; Mansour, M.A.; Barkmeier, L.D.; Hodgson, K.J.; Ramsey, D.E.; and Sumner, D.S. Springfield, IL. Journal of Vascular Surgery 1994; 19:1052-8.

Hemodynamic effects of intermittent pneumatic compression in patients with critical limb ischemia. Labropoulos, N.; Leon, L.R.; Bhatti, A.; Melton, S.; Kang, S.S.; Mansour, A.M.; and Borge, M. The Department of Surgery, Loyola University Medical Center, Maywood, IL. Journal of Vascular Surgery, October 2005; Volume 42, Number 4: 710-716

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Compressing Ischemic Limbs and Why It’s Beneficial

To download a printable PDF of this article, click here:  Compressing Ischemic Limbs and Why It’s Beneficial

The Misconception

Is it true that arterial occlusive disease is an absolute contraindication for intermittent pneumatic compression (IPC)?

The Answer

Not at all!

Unfortunately, many medical professionals are under the impression that applying even a small external pressure to an ischemic limb with reduced distal arterial pressures may serve to reduce or completely stop the already-compromised blood flow. This article presents strong evidence that, contrary to popular belief, IPC can bring life-changing benefits to those who cannot undergo revascularization.

History

Part of the reason this dogma exists is because, for many who consider it, applying IPC to ischemic limbs seems counterintuitive and likely dangerous. Also contributing to this myth are the literature reviews written by investigators as far back as 1934 who showed a poor understanding of the physiological mechanisms. Though these measured acute effects of compression on increased blood flow in ischemic limbs and relief of symptoms, the assessments made about IPC therapy were muddled due to the use of a great variety of compression schemes and devices. This lack of clarity resulted in literature that only served to feed misgivings about IPC as a treatment modality.

Physiological & Optimization Studies | ACI Medicalarteriovenous pressure gradient

To demystify the true value of IPC, our goal was to determine the physiological mechanisms of action, to optimize IPC design for maximal acute effect, and to determine if there is a clinical benefit to patients with lower extremity ischemic disease.

We started with physiological studies1 with compression applied to the dependent limb, which showed these acute mechanisms:

  • Increased arterial-venous pressure gradient
  • Reduced peripheral resistance
  • Abolition of the veno-arteriolar reflex

Further studies2 concerned optimization:

  • Pressure:  at least 120 mmHg
    This high pressure is required to empty the veins in the dependent limb, which temporarily reduces venous pressure to near zero and increases the arterial-to-venous pressure gradient and therefore, flow. Reducing venous pressure also serves to temporarily abolish the veno-arteriolar reflex, which allows for arteriolar dilation.
  • Timing:  3 second pulses followed by 17 seconds of low pressure
    An essential requirement for an arterial pump is the ability to quickly reach inflation and deflation pressures with rise times of 0.25 to 0.30 seconds and fall times under 0.5 seconds.  This rapid squeeze and release creates blood velocities that apply shear stress to the endothelium which releases nitric oxide and further supports the large acute vasodilatory effect in the arterioles.
  • Compressed tissues:  foot, ankle and calf regions
    In order to maximize blood flow through the major arteries and to the toes where ischemic disease often presents, we found that a circumferential foot bladder including the ankle should be compressed first, followed one second later by compression of the calf with a relatively large asymmetrical bladder.

Randomized Controlled Trials | ACI Medical

Intermittent Claudication

Once the arterial IPC device was optimized, three randomized controlled trials3 were performed on patients with intermittent claudication. Not only did these trials yield significantly increased walking distances of two to three times, but also sustained “permanent” improvements begged the question, “What long term mechanisms might be at work?”

Limb Salvage due to Arteriogenesis

Further studies4 showed that arteriogenesis (the opening of collaterals) was responsible for improved ABI’s, PVR’s, toe pressures and popliteal flow. A recently published study from 20105 reported a 94% limb salvage rate at 3.5 years in patients who were unable to undergo revascularization procedures.

Arterial Assist Device, NOT Lymphedema Pump

ArtAssist Arterial Assist Device

ArtAssist®…The Arterial Assist Device®

Today, it is widely-known that IPC devices are designed for prophylaxis against deep vein thrombosis (DVT) and for treatment of lymphedema. However, the understanding behind these devices does not coincide with our exploration of IPC to treat severe forms of arterial disease. Lymphedema and DVT devices do not apply enough pressure to the dependent limb to adequately empty the veins, nor do they apply and release pressure rapidly enough to stimulate release of nitric oxide (NO). While such devices will not significantly improve blood flow in the ischemic limb, it is difficult to say whether they would be harmful without further study.

References in this Publication

  1. Effect of intermittent pneumatic foot compression on popliteal artery haemodynamics. Delis, K.T.; Labropoulos, N.; Nicolaides, A.N.; Glenville, B.; and Stansby, G. Imperial College School of Medicine, Academic Vascular Surgery, St. Mary’s Hospital, London, UK. Eur J Vasc Surg, p. 270-277, vol. 19, no. 3, March 2000.
  2. Optimum intermittent pneumatic compression stimulus for lower-limb venous emptying. Delis, K.T.; Azizi, A.A.; Stevens, R.J.G.; Wolfe, J.H.N. and Nicolaides, A.N. Irvine Lab for Cardiovascular Investigation and Research Academic Vascular Surgery, Imperial College School of Medicine, St. Mary’s Hospital, London, UK. Eur J Vasc Endovasc Surg 19, 261-269 (2000).
  3. Improvement in walking ability, ankle pressure indices and quality of life in vascular claudication using intermittent pneumatic foot and calf compression:  a randomized controlled trial. Delis, K.T.; Nicolaides, A.N.; Cheshire, N.J.W.; Wolfe, J.H.N. St. Mary’s Hospital, London, UK. British Journal of Surgery December 2002; Volume 88, Issue 4:605-606.
  4. Angiographic improvement after rapid intermittent compression treatment (ArtAssist®) for small vessel obstruction. Van Bemmelen, P.; Char, D.; Giron, F.; and Ricotta, J.J. Dept. of Surgery, Div. of Vascular Surgery, State University of New York at Stony Brook, NY. Ann Vasc Surg 2003; 17:224-228.
  5. Sequential compression biomechanical device in patients with critical limb ischemia and nonreconstructable peripheral vascular disease. Sultan, S.; Hamada, N.; Soylu, E.; Fahy, A.; Hynes, N. and Tawfick, W. Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Journal of Vascular Surgery 2011; 54:440-447.
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