Apligraf® in Practice – Dr. Matthew Garoufalis
Case presented by Matthew Garoufalis, DPM, Veterans Administration Health Care System, Chicago, Illinois.
Patient: E.S.*
Wound: Large, Recurrent Venous Leg Ulcers†
Age: 80 years old
Sex: Male
Duration of the condition: 50 years
*Not the patient’s real initials.
†The case presented here represents the experience of a single patient and may not be typical of all patients.
History
Figure 1:
Preapplication.
E.S. is an 80-year-old man whose history of venous leg ulcers began 55 years ago, when a leg wound suffered during World War II would not heal. In an effort to correct his venous insufficiency, the patient underwent vein-stripping 20 years later, without success. E.S. states that he has had "every wound product and no results." Additionally, he has a history of hypertension, coronary artery disease, myocardial infarction and pulmonary embolism.
Evaluation
Figure 2:
Day 2 - Meshed (perforated) Apligraf appears yellowish green.
E.S. presented in March, 1999, with multiple venous leg ulcers of >10 years’ duration on his right leg. Treatment with inelastic compression therapy (Unna’s boot) and platelet-derived growth factor was initiated for 21 weeks prior to the application of Apligraf.
Treatment
Figure 3:
Week 3 - Granulation tissue is apparent.
Upon examination, the patient had multiple ulcers on his right leg that had coalesced (Figure 1):
- Anteromedial—irregular shaped (6.5 cm x 2.5 cm)
- Lateral—rectangular shaped (7 cm x 3 cm)
- Posterior—circular shaped (9 cm x 7 cm)
- Medial—"S" shaped (7 cm x 4.5 cm)
Scarring from previous wound healing was apparent on the periphery of the ulcerated area.
Due to the size of the ulcer, 2 units of Apligraf were used to cover the wound. Apligraf was meshed to allow drainage and prevent buildup of fluid (meshing ratio: 1.5 to 1). Apligraf was held in place with a contact layer of a nonadherent surgical dressing soaked in a gentamicin solution, a secondary absorbent dressing and a tertiary compression bandage. The dressing was changed weekly.
Clinical Observations
Figure 4:
Week 8 - Epidermal coverage is evident.
- Day 2, note the yellowish green appearance at the time of the first full dressing change (Figure 2). Since there are no clinical signs of infection (pain, swelling, heat, redness, purulent discharge), the wound is left alone and rebandaged.*
- By week 3 (Figure 3), the ulcer is filling in with diffuse, red, granular tissue.
- By week 8 (Figure 4), the ulcer is markedly reduced in size and epidermal coverage is apparent.
- By week 16 (Figure 5), the ulcer is 100% closed.
Discussion
Figure 5:
Week 16 - 100% closure.
With Apligraf, we were able to close this patient’s long-standing ulcerations and bring about a marked change in his status. Although he still had some pain in his feet due to venous insufficiency, he stated that this is "the best" he has been in over 50 years.
Apligraf is indicated for use with standard compression therapy in venous ulcers of at least 1 month’s duration that have not adequately responded to conventional ulcer therapy. Apligraf should not be used on infected wounds or on patients with known hypersensitivities to any components of Apligraf or the shipping medium. Please consult the complete prescribing information for a description of epidermal and dermal elements contained in Apligraf.
*Unless there are clinical signs of infection (pain, swelling, heat, redness, purulent discharge), the wound should be left alone, rebandaged, and reassessed at the next follow-up visit.
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