Can Hyperbaric Oxygen Therapy (HBOT) help with Peripheral Artery Disease (PAD)?

Hyperbaric Oxygen Therapy for Peripheral Artery Disease

Hyperbaric oxygen therapy (HBOT) has limited evidence supporting its use for peripheral artery disease (PAD) and is not recommended as a primary treatment. 1

Current Recommendations for PAD Management

• The primary approach for PAD management should focus on revascularization when possible, along with comprehensive medical therapy and preventive foot care 1
• For patients with chronic limb-threatening ischemia (CLTI), the cornerstone of treatment includes:
  • Revascularization for adequate perfusion
  • Debridement of nonviable tissue
  • Management of infection and inflammation
  • Pressure offloading when appropriate
  • Proper wound care and dressings 1

Evidence on HBOT for PAD

Limited Efficacy in Standard PAD

• Current guidelines classify HBOT as having uncertain effectiveness (Class IIb, Level C-LD) for patients with critical limb ischemia (CLI) 1
• Studies on HBOT have primarily focused on diabetic foot ulcers rather than PAD without diabetes 1
• The literature evaluating HBOT has not demonstrated consistent long-term benefits on wound healing or improving amputation-free survival compared with standard treatment 1

Potential Role in Specific Scenarios

• HBOT may be considered as an adjunctive therapy to revascularization for wound healing specifically in the context of CLTI with diabetic foot ulcers 1
• One small RCT in patients with foot ulcers and PAD (ABI <0.80 or TBI <0.70) showed a significant decrease in ulcer area at 6 weeks, but no significant differences at 6 months in ulcer size, complete healing, or amputation rates 1
• A meta-analysis showed HBOT may reduce major amputation rates in diabetic foot ulcers with arterial insufficiency (10.7% vs 26.0%), but did not improve wound healing, minor amputation rates, or mortality 2

Patient Selection for HBOT

• Transcutaneous oxygen measurements (TCOM) can help identify patients who might benefit from HBOT 3, 4
• Patients showing an increase in tissue oxygen tension of ≥10 torr when breathing pure oxygen may be more likely to benefit from HBOT 3
• HBOT should only be considered after standard treatments have failed and in patients with appropriate physiological markers suggesting potential benefit 4

Alternative Approaches for "No Option" PAD Patients

• For patients with CLTI who are not candidates for revascularization, guidelines recommend considering:
  • Arterial intermittent pneumatic compression devices (Class IIb, Level B-NR) to augment wound healing or reduce ischemic pain 1
  • Venous arterialization for limb preservation when arterial revascularization is not possible (Class IIb, Level B-NR) 1
• Prostanoids are not indicated in patients with CLI (Class III: No Benefit, Level B-R) 1

Risks and Limitations of HBOT

• HBOT is time-consuming, costly, and not without risks 3, 5
• Common complications include barotrauma to the ears, which can occur in up to 43% of patients 5
• Some studies report dismal outcomes with HBOT for lower extremity wounds, with high rates of non-improvement and subsequent need for surgical procedures 5

Conclusion

For patients with PAD, HBOT should not be considered a primary treatment option. The focus should remain on established therapies including revascularization, proper wound care, and medical optimization. HBOT may be considered as an adjunctive therapy only in specific cases of CLTI with diabetic foot ulcers when standard treatments have failed and physiological measurements suggest potential benefit.