Dr. Adiraju is a trained Cardiologist and Endovascular Specialist and is recognized as a respected expert in the field of Vascular Interventional Therapy. He has been in practice for 17 years and is a Guest Faculty Member at Trans Cather Therapeutics (TCT), an internationally renowned cardio/endovascular seminar held yearly.

RENU-CA Research Institute was established in 2005 by Dr. Adiraju to develop novel approaches to revascularization and improved autonomic function through the use of advanced endovascular techniques. In June of this year, the Institute hosted a seminar entitled "Novel Approaches to Balanced Arterial and Venous Intervention for Optimal Foot Care" as part of the Comprehensive Endovascular Center Series (COMENCENSE).

Dr. Adiraju has been using the Circulator Boot system since 2006.  His practice includes two bi-lateral Mini-Boot systems that operate at maximum patient capacity weekly. We asked Dr. Adiraju to share his experience using Boot therapy as part of his comprehensive vascular protocol:

"At RENU-CA Research Institute, our mission for the past 10 years has been to implement advanced revascularization modalities with minimal endothelial injury and risk factor intervention. We accomplish this by using novel approaches which include dysautonomia regulation that addresses the underlying pathophysiology with minimal pharmacologic intervention. We have had great success in limb salvage and aggressive risk factor and metabolic regulation control using these modalities.

The physiology behind end-diastolic pneumatic compression improves peripheral capillary venous tone and has systematic benefits through its affect on autonomic function. These factors drove us to incorporate Circulator Boot therapy into our optimal foot care program. Under the Comprehensive Wound Care and Endovascular Revascularization Program (COWER), a combined modality approach has been instituted with great strides in acute and long-term outcomes for non-healing wounds, ischemic limb salvage, ambulatory dysfunction, chronic venous stasis/dermatitis, PTS (post-thrombotic syndrome/peripheral venous HTN), RSD, EM and chronic diabetic foot.  We have also observed systemic benefits from Circulator Boot treatment in DM-II and cardiomyopathy management in our early clinical experience.

Standard evidence based treatment modalities currently practiced such as surgical revascularization, conventional angioplasty/stenting, standard risk factor interventions, hyperbaric oxygen (HBO) therapy, (particularly in PVD and foot care) have had sub-optimal long term results. The pathophysiology limitations of these modalities result in local effects that are temporary at best. For example, HBO therapy requires an optimal milieu to be effective that includes a balance between local anti-oxidant and pro-oxidant substances, hormones, and vaso-active substances. Without a proper milieu, HBO can be paradoxically toxic to the tissue. As a matter of course, response to revascularization and HBO can be enhanced by combining these therapies with autonomic regulation and Circulator Boot therapy."

Physiology

"I believe the peripheral vascular system, compared to rest of the body vasculature, is different and unique in humans for the following reasons:

·      Humans are upright beings and therefore require a constant force within the vasculature against gravity to maintain blood column and circulation.

·      Arterial tubes in the lower extremities run straight and long requiring more tensile force to maintain a blood column, therefore they are exposed to more shear force than anywhere in the body. Arteries in the lower extremities not only have muscle layer in the wall but are also embedded in strong muscular wraps.

·      Veins run parallel to the arteries and are enclosed in a common fascial sheath with the arteries.  Arteries and veins are closely interconnected by an extensive arterio-venous capillary network. This setup while lending support and reinforcement to each other, also sets up a dependency whose stability is directly related to a-v capillary tone.  Arteries pulsate to pump blood with the heartbeat, veins on the contrary are passive conduits that facilitate flow down a pressure gradient back to the heart.  Central Venous Pressure (CVP) fluctuation through the cardiac cycle predominantly determines this flow.  In lower extremities however, venous return is an active, sophisticated process against gravity that is actively regulated as an essential function by the body's auto regulatory mechanism, the Autonomic System. This works in tandem with other essential functions of the body such as hormone regulation, heartbeat ,and breathing as part of the overall cardio respiratory regulation. Frank-Starling forces and Bain-bridge reflex are the mechanisms utilized through vasa-nervosum  (sympathetic and parasympathetic fibers innervating the vascular walls) to accomplish this function.

·      Venous returns occur during the diastolic portion of the cardiac cycle. There are three phases that occur here: an early phase, a mid-phase and an end-diastolic phase. The diastolic portion of the cardiac cycle takes place when the ventricle, the main pumping chamber of the heart, is relaxing. The early diastolic phase is when ventricular pressure falls below the arterial pressure, therefore venous flow is down the gradient - 25% return happens during this phase. The mid-phase is during the time when the atrio-ventricular valves are open and it is a passive process - 15 - 25% return happens during this phase. The end-diastolic phase is an active phase when atria contract and push blood forward. The CVP rises during this phase therefore the peripheral capillary venous system in the lower extremities need to actively pump to maintain venous return. This is why the saphenous a-v capillary bed in the calf muscle is considered the second heart of our body. Close to 50% of the venous return occurs during this phase.

·      Vascular Endothelium is a unique structure that is multi-tasking. It functions as an absorbative, protective, vasoactive and physiologically interactive organ that is responsible for vascular integrity and local tissue homeostasis. The Autonomic System through endothelial modulation  and physiologic auto-regulation, maintains a delicate balance between anti-oxidant (super oxide desmutase, catalase) and pro-oxidative species (free radicals or reactive oxygen species-ROS) in the vascular wall. This balance determines the NO-nitric oxide bioavailability, local hormones and vasoactive substances such as endothelin, leukotrienes, prostaglandins, VDGF-vascular derived growth factor, pro and anti-coagulants, etc. ,that are responsible for vascular homeostatis and tissue integrity. "

The above impressions are clinical views and the experiences of Dr. Ramesh Adiraju.  All intellectual property rights are reserved.