Effect of PEM Treatment of Superficial Axial and Tributary Vein Reflux on Improvement of Wound Healing in VLUs

Compression therapy and polidocanol endovenous microfoam (PEM) are both used for the
treatment of venous leg ulcers (VLUs), but they do so by different mechanisms.

Compression therapy applied by a wound care professional has been demonstrated to improve
healing rates in patients with existing VLUs and to reduce ulcer recurrence, and is used
consistently by treating physicians. Compression therapy consists of hosiery, tubular
bandages and bandage systems comprising two or more components, which provide graduated
compression to the lower limb in order to improve venous return and to reduce edema.

Polidocanol endovenous microfoam (PEM) is an injectable foam medication that is used to treat
symptoms of venous disease, including venous leg ulcers (VLUs). The medication
("polidocanol") is in the foam ("endovenous microfoam"). PEM is injected through a catheter
or by direct injection into the malfunctioning vein. The foam fills and treats the desired
section of the vein, thereby collapsing the diseased vein. When the malfunctioning vein
collapses, the microfoam is deactivated and blood flow shifts to healthier veins nearby.

Inclusion Criteria:

- Age ≥ 18 years old

- Active VLU with a CEAP classification of C6

- Non-healing VLU ≥ 1 month but not greater than 24 months

- In the case of more than one ulcer, the largest ulcer (compliant with study criteria)
will be chosen as the study ulcer and treated in the study. Other ulcerations, if
present on the same leg must be at least 2cm apart from the study ulcer.

- Demonstrable GSV insufficiency (as per the Society for Vascular Surgery [SVS] and the
American Venous Forum [AVF] Guidelines) via venous insufficiency study (VIS) (11)

- VLU considered non-healing (clinically defined as ≤70% wound improvement) after a 4-5
week run-in period with compression therapy

- Venous leg ulcer size ≥ 2cm2 within the great saphenous distribution and must be
visualized in one plane to allow for image collection of the entire wound in one photo
by the Silhouette device.

- The ulcer must extend through both the epidermis and dermis, with no exposed tendon or
bone

- The ulcer must be located below the knee

- The ulcer bed must have some viable tissues with some granulation tissue

- Able to tolerate effective compression bandaging

- Patients able to walk independently with or without mobility aids

- Ability to comprehend and sign an informed consent document and complete study
questionnaires in English

- Able and willing to attend all follow up visits

Exclusion Criteria:

- Age < 18 years old

- Small saphenous vein (SSV) distribution VLUs

- Patients who had previously received interventions for underlying venous disease or
prior VLU treatments that would not be considered to be conservative, in the opinion
of the principal investigator

- Exposed bone, tendon, or fascia

- Deep vein reflux unless clinically insignificant in comparison to superficial reflux

- Patients with leg ulceration etiology other than venous insufficiency

- Severe rheumatoid arthritis

- History of radiotherapy to the ulcer site

- Uncontrolled congestive heart failure (left or right sided heart failure)

- Receiving corticosteroids or immune suppressive therapy

- Active clinical infection of the ulcer site, however, patients may be entered into the
study after successful treatment of infection

- History of collagen vascular disease

- History of known malnutrition (albumin <3.0 g/dL)

- History of known uncontrolled diabetes [hemoglobin A1c (HgbA1c) >8.0%]

- History of known arterial insufficiency [ankle-brachial index (ABI) <0.7,
transcutaneous oxygen (tcpO2) <35 mmHg, or toe-brachial index (TBI) <0.4]

- Signs of cellulitis, osteomyelitis, or necrotic or avascular ulcer bed(s)

- Active sickle cell disease

- Patients diagnosed with DVT or phlebitis in the affected limb in the last 6 months, or
with acute pulmonary embolism (PE) in the last 6 months (contraindication to PEM)

- Known allergic response to polidocanol or heparin, including history of
heparin-induced thrombocytopenia, and/or multiple allergic reactions (contraindication
to PEM)

- Chronic renal disease, if deemed by the principal investigator to be severe enough to
interfere with wound healing

- Known active or recurrent cancer, or currently receiving chemotherapy or radiation
therapy

- Poorly controlled asthma

- Pulmonary edema

- Major surgery, prolonged hospitalization, or pregnancy within 3 months of screening

- Minor surgery within 1 month of screening

- Current alcohol or drug (illicit or prescription) abuse

- Pregnant or lactating women

- History of stroke

- Unable to comply with the procedures described in the protocol

- Unable to comply with compression therapy recommendations

- Unable to give informed consent

- Non-English speaking

- Enrolled in a clinical evaluation for another investigational wound-care device or
drug