Hyperbaric Oxygen Therapy in Management of Diabetic Foot Ulcers: Indocyanine Green Angiography May Be Used as a Biomarker to Analyze Perfusion and Predict Response to Treatment

Abstract

Summary: The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Chronic wounds: Treatment consensus

“… 93 Since this last Cochrane review, numerous new studies have been conducted, including both randomised controlled studies and newer ‘big data’ studies based on large data bases derived from the electronic medical record. These newer techniques again yielded conflicting results with one study showing no impact on amputation outcomes 97 while a later study on the same data base demonstrated efficacy in a subset of more severe DFUs (Wagner 3 and 4) in terms of wound closure. 98 , 99 Clearly, how the analysis is performed and how the questions are asked can skew results in different directions.…”

Perfusion Parameters in Near-Infrared Fluorescence Imaging with Indocyanine Green: A Systematic Review of the Literature

“…Hajhosseini et al researched the application of ICG angiography in the prediction of diabetic wound healing following hyperbaric oxygen therapy in cases and controls [ 21 ]. Absolute fluorescence intensity was selected as the perfusion parameter, showing a significant improvement between pre- and post-hyperbaric oxygen therapy in the patient group ( p < 0.0015).…”

Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection

“…Intraoperative angiography using indocyanine green (ICG) is a well‐described method for assessing tissue perfusion and has been suggested to be an accurate means of predicting flap failure 18,23,24 . The technology has been shown to correlate with the risk of wound healing complications in other disciplines, including critical limb ischemia 25,26 . This imaging modality is routinely used in other surgical fields and practices, including colorectal and plastic surgery.…”

“…18,23,24 The technology has been shown to correlate with the risk of wound healing complications in other disciplines, including critical limb ischemia. 25,26 This imaging modality is routinely used in other surgical fields and practices, including colorectal and plastic surgery. This system is now routinely part of our clinical practice for all patients undergoing resection of a previously irradiated soft tissue sarcoma; however, the clinical utility of intraoperative angiography in predicting wound complications in highrisk patients undergoing resection of soft tissue sarcoma of the extremities is not well understood.…”