Original Article

Vascular
2015, Vol. 23(6) 580–585
! The Author(s) 2014
Autologous platelet-rich plasma in Reprints and permissions:
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treatment of chronic venous leg ulcers: DOI: 10.1177/1708538114563824
vas.sagepub.com
A prospective case series

Seyhan Yilmaz1, Eray Aksoy1, Suat Doganci2,

Adnan Yalcinkaya1, Adem I Diken1 and Kerim Cagli1

Abstract
Study: We report our results on a case series of 19 patients receiving platelet-rich plasma application in treatment of
patients with chronic unhealing venous leg ulcers.
Material and methods: There were 16 males and three females with a mean age of 38.55  16.46 years. Planimetric
size measurements were performed and pain was tested throughout the treatment period. Follow-up was made in seven-
day periods. Patients received 5 ml of platelet-rich plasma for each 5 cm2 of the wound surface with half of the amount
being injected 1–2 mm deep into the wound and the wound surface was covered with the remaining half.
Results: Complete wound healing occurred in 18 of 19 patients (94.7%) within a mean of 4.82  2.16 week. There were
significant reductions in wound area among all consecutive measurements except for first week. A significant reduction in
wound volume was apparent even in first week and sustained among consecutive measurements.
Conclusion: Platelet-rich plasma seems effective in terms of promoting healing of venous leg ulcers. Improvement in
wound depth was slightly more prominent than that in wound area, indicating a potential role of platelet-rich plasma
especially in deep venous ulcers.

Keywords
Platelet-rich plasma, chronic venous insufficiency, wound

disease still may remain untreated in a significant pro-

Introduction
Lower extremity wound ulcers constitute an important
health problem disrupting patients’ life activities and
causing high treatment costs. Venous disease was
reported to be the underlying cause in more than half
of the patients with leg ulcers and it is also involved in
the disease process in up to 25% of other forms.1
Prevalence of active venous leg ulcers (VLU) was
reported to be around 0.5% in different populations.2
Although there has been an increasing trend towards
prevention of chronic venous leg ulceration in patients
with primary chronic venous disease,3 a large number
of patients with VLU, especially those with secondary
(post-thrombotic) chronic venous insufficiency, still
require further therapies for wound care that is com-
bined to their existing treatment.4
Some forms of chronic VLU may respond well to
known treatment options including multi-layer ban-
dage compression systems, stockings, drug therapy,
foam sclerotherapy, and open surgery, whereas the
portion of patients since each of the treatment options
has its own limitations. Whatever the treatment is, com-
plete healing of the wound takes weeks to months even
though it is achieved.5
Application of autologous platelet-rich plasma
(PRP) has gained popularity in plastic and reconstruct-
ive surgery and orthopedics since this therapy was
shown to be effective and safe in terms of better survival
of fat tissue and bone grafts.6,7 More recently, PRP has
begun to be used for the purpose of promoting the
healing process of surgical wounds and skin ulcerations
1
Department of Cardiovascular Surgery, Hitit University Corum
Education and Research Hospital, Turkey
2
Department of Cardiovascular Surgery, Gulhane Medical Military
Academy, Turkey
Corresponding author:
Seyhan Yilmaz, Camlik St. No:2, Corum, Turkey.
Email: drlabarna@gmail.com
Yilmaz et al.
and its application has shown to induce migration of
specific cell types.8
Data is limited on use of PRP to treat chronic lower
extremity wound ulcers of venous etiology. We herein
report our institutional results and experiences regard-
ing the use of an adopted approach for PRP application
in treatment of patients with chronic VLU who were
unresponsive to conventional methods.
Material and methods
The study was approved by the local ethics committee
(Gaziosmanpasa University 13.02.2014/83116987-046).
Patients presenting with chronic VLU to the depart-
ment of cardiovascular surgery were informed about
the study protocol and the treatment. All patients
signed informed consents to receive the planned treat-
ment and to take part in the research. This study
reports a case series of patients. The study was con-
ducted in a tertiary setting between April and July
2014 and made up of 19 patients who presented with
chronic VLU and considered eligible for the study.
There were 16 males and three females with a mean
age of 38.55  16.46 years. Patients were considered eli-
gible if they had lower extremity wound ulcers at the
level of ankle (CEAP classification VI) with an area of
at least 4 cm2, duplex ultrasound confirmed deep
venous reflux of any degree or superficial venous
reflux with a duration longer than half a second and/
or obstruction at the target extremity with normal
arterial flow and if they were unresponsive to
common conventional treatment procedures including
local wound care, topical antibiotics, and synthetic
wound dressings for at least two months. Patients
who had more than mild venous reflux (duration
longer than half-a-second) within greater saphenous
vein or saphenous-femoral vein reflux requiring oper-
ation were not included. Pregnant women and patients
having a history of any malignant disease, long-term
steroid use, coagulation disorders, and severely dis-
abled patients were not included. Patients having
exudative and discharging wounds indicating the pres-
ence of active local infection were also excluded.
On the day of admission, planimetric size measure-
ment of the wound were performed, a photograph
was taken and the patients were asked to rate their
pain using a 10 cm visual analog scale (VAS)9 before
receiving the PRP procedure. After the treatment,
follow-up information was collected in seven-day per-
iods. At each follow-up, planimetric measurement and
VAS scoring was repeated and a photograph was
taken. Ulcer healing rates and time to complete heal-
ing was computed and each patient was interviewed
to find out whether the treatment caused any unde-
sired effect.
581
Treatment protocol
Before the application of PRP, all wounds were
inspected carefully for any necrotic tissues that may
cause poor healing. Wound swab cultures were taken.
Surface of the wound was rinsed with physiologic saline
and the healthy tissue around the wound was cleaned
with antiseptic solution (hypochlorous acid). Necrotic
tissues were carefully debrided under sterile conditions.
PRP was prepared using Easy PRP KIT (Neotec
Biotechnology, Istanbul, Turkey) system. In aseptic
conditions, 20 ml of venous blood was drawn from
antecubital vein and added into a 9/1 acid citrate dex-
trose containing test tube. The tube was centrifuged at a
rate of 5000 r/min for 15 minutes to separate red blood
cells from platelets and plasma. Then, platelet and
plasma containing supernatant and thin white layer
was collected and centrifuged at a rate of 2000 r/min
for 5–10 min to harvest PRP. The 2–3 ml bottom
layer was collected and added to 0.3 ml of 10% calcium
chloride for each 1 ml of PRP. Immediately after
obtaining the PRP, we administered the entire sub-
stance into the wound applying 5 ml of it for each
5 cm2 of the wound surface. Half of the amount was
injected 1–2 mm deep into the wound and then the
wound surface was covered with the remaining half.
The lesion was then covered with soft silicone polyur-
ethane foam dressing (MepilexÕ , Göteborg, Sweden)
and a single layer ace wrap compression bandage was
applied by the same care-giver to the leg with the tight-
ness kept constant. The wound dressings were changed
daily while the wound only being rinsed with physio-
logical saline. PRP administration was repeated weekly
until achieving complete wound healing or the treat-
ment was intended to be stopped if the patient had
less than 30% reduction in wound surface area at the
end of three consecutive sessions. Patients did not
receive any other type of wound care or therapy until
completion of the PRP protocol. Pain was treated with
non-steroid anti-inflammatory drugs as needed.
Patients were also given low-molecular weighted hep-
arin for prevention of thromboembolic events during
hospital stay. None of the patients received endovenous
or open venous surgery during the study period.
Complete wound healing was defined as documenta-
tion of full skin epithelization by inspection, planimet-
ric measurement, and photography.
Statistical analysis
All statistical analyses were performed using Medcalc
statistical software. Visual histograms and analytical
methods (Shapiro-Wilk’s test) were used for determin-
ation of normal distribution. Continuous variables
were defined by the mean  standard deviations.
582 Vascular 23(6)

Paired values for planimetric data including wound

area (cm2) and wound volume (wound area  wound
depth, cm3) were compared with paired samples t-test
among consecutive times of study period.

Results
Patients have been suffering from the VLU for a mean
time of 6.96  4.96 months. Baseline characteristics
were as follows; diabetes was present in five patients,
hypertension in eight patients, tobacco use in 11
patients, coronary artery disease in three patients,
renal failure in one patient and cerebrovascular disease
in one patient. Three out of 19 patients had duplex
ultrasound confirmed venous thrombosis in deep
veins and six patients had superficial vein thrombosis.
Treatment was completed in all patients with a mean
follow-up of 6.92  2.62 weeks. Patients received a
mean of 3.57  1.83 sessions of PRP treatment
(median: 4 sessions, ranging from 1 to 6 sessions).
Complete wound healing occurred in 18 of 19 patients
(94.7%) within a mean of 4.82  2.16 weeks, whereas in
one patient, reduction in wound area was 31% at the
end of fourth session and the treatment stopped.
Wound healing was complete within five weeks in
13/19 patients (68.4%).
In paired comparisons that were performed between
consecutive weeks, planimetric wound area did not
show significant reduction in first week follow-up
(p ¼ 0.368), whereas there were significant reductions
among all consecutive measurements thereafter
(p ¼ 0.004 between first and second weeks, p < 0.001
between second and third weeks and third and fourth Figure 1. (a) Photograph taken before treatment, (b) and (c)
weeks, p ¼ 0.014 between fourth and fifth weeks, and healing process.
p ¼ 0.39 between fifth and sixth weeks). A significant
reduction in planimetric wound volume was apparent
even in first week follow-up and sustained among con- treatment of chronic VLU that was unresponsive to
secutive measurements (p < 0.001 between first and previous treatment attempts using conventional treat-
second, second and third, third and fourth weeks; ment methods. More than half of the patients had com-
P ¼ 0.014 between fourth and fifth weeks; and plete wound healing within five weeks of time with the
p ¼ 0.058 between fifth and sixth weeks) (Figure 2, improvement in wound depth being more prominent
Figure 3, Table 1). Mean changes and % average than that in planimetric wound area. An average of
reductions in wound dimensions are shown in Figure 1. 50% area reduction in wound is achievable within
Mean VAS score of the patients was 5.42  1.30 before two weeks and thus, the treatment seems promising in
treatment, 5.21  1.54 at first week (p ¼ 0.215), 2.78  0.91 terms of accelerating the healing process of chronic
at second week (p < 0.001), 1.63  0.68 at third week lower extremity wounds of venous etiology. The pro-
(p < 0.001), and 1.42  0.50 at fourth week (p ¼ 0.215). cedure was safe in terms of not resulting in any deteri-
None of the patients suffered complications or undesired oration in wound status and it is likely to be effective
effects that are directly related with the PRP treatment, both in patients with primary chronic venous insuffi-
including skin irritation, pain or allergic reaction. ciency and in those with post-thrombotic venous
insufficiency.
Earlier experimental studies on use of PRP suggested
Discussion
that PRP has potential of accelerating the healing pro-
In a case series of 19 patients, we achieved excellent cess by enhancing neovascularization in reconstruction
results applying a standardized PRP protocol for of transected tendons having poor vascularity.10 It was
Yilmaz et al. 583

Figure 2. Change in mean wound dimensions throughout the study period.

Figure 3. Average percentage change in wound dimensions throughout the study period.

Table 1. Paired comparisons among planimetry values of wound area and wound volume throughout the study period.

Before First week Second week Third week Fourth week Fifth week Sixth week
treatment n ¼ 19/19 n ¼ 15/19 n ¼ 13/19 n ¼ 11/19 n ¼ 6/19 n ¼ 4/19

Wound area (cm2) 8.61  3.44 7.98  4.65 5.23  2.38 3.71  1.67 2.61  1.38 2.41  0.91 2.62  0.75
p value for repeated p ¼ 0.368 p ¼ 0.004 p < 0.001 p < 0.001 p ¼ 0.014 p ¼ 0.39
comparisons
Wound volume (cm3) 4.48  2.10 3.45  1.61 1.30  0.60 0.74  0.33 0.32  0.17 0.30  0.11 0.26  0.07
p value for repeated p < 0.001 p < 0.001 p < 0.001 p < 0.001 p ¼ 0.014 p ¼ 0.058
comparisons
584
also shown that 5% calcium chloride activated PRP
stimulates human dermal fibroblast proliferation indi-
cating its promising role in cosmetic dermatology.11
Another experimental model provided substantial evi-
dence to support that platelet-rich fibrin matrix – a
variant preparation with similar properties – induce
endothelial cell proliferation which may suggest an
explanation of wound healing effect of PRP.12
There have been an increasing number of clinical
studies regarding use of PRP in chronic wounds.
Serra et al.13 compared the effect of platelet-rich gel
in 26 diabetic patients undergoing metatarsal amputa-
tion with 32 patients serving as controls. Healing rate
was 96.15% against 59.37% in patients receiving and
not receiving platelet-rich gel, respectively. In a
Japanese wound care program, topical PRP adminis-
tration provided an 83% healing rate within 145 days in
40 patients with lower extremity chronic wounds of
ischemic and diabetic etiology.14
Very recently, Roubelakis et al.8 reported their study
of 17 patients with chronic wounds of different etiolo-
gies including dehiscent sternal wounds and ischemic
neuropathic wounds. In this study, the majority of
wounds was exudative or necrotic and was located in
the lower extremity. The authors reported an average
volume reduction of 34.1% in all types of ulcers within
eight weeks by applying an average of 9.5 separate PRP
sessions. This clinical study supported that PRP has
potential of regulating wound healing by acting on
cell migration and proliferation. Based on our findings
and those above, we think that patients with VLU may
respond better to PRP treatment than those having
ischemic and neuropathic wounds in terms of faster
recovery and higher amount of the closure.
Compression therapy is the most commonly pre-
ferred option in treatment of VLUs. However, success
of wound healing using compression stockings is
dependent on a number of risk factors including, sur-
face of the wound, history of deep venous thrombosis,
inadequate reduction in calf circumference, and wound
depth.15 Risk factors such as wound surface area and
especially wound depth which directly reflects the indi-
vidual characteristics of any given wound may require
additional measures to promote healing. Data regard-
ing the use of PRP is quite limited to justify its role both
for such purpose and also to warrant its use over stand-
ard compression bandages. In one wound registry ana-
lysis of patients receiving PRP, where wound and
wound depth >50% were among primary outcomes,
PRP caused a significant reduction in wound depth
and the reduction was most prominent in patients
with venous ulcers. However, this contribution is sub-
ject to debate because there were only three patients
with venous leg ulcers in this study.16 In another pro-
spective case series, 16 out of 65 non-healing wounds
Vascular 23(6)
were of venous etiology and PRP resulted in a
56.1  35.2 volume reduction and 43.1  32.4% area
reduction in venous ulcers following a mean of
2.4  1.5 weekly or twice weekly sessions of PRP appli-
cation.17 Given the better healing rates we gathered, we
recommend that PRP treatment not be given more fre-
quently than weekly intervals, not be ceased after a few
attempts and be continued at least four to six weeks to
achieve satisfactory healing of VLUs.
Our study was not the first reporting use of PRP in
VLUs. In a very recent study, Sarvajnamurthy et al.18
reported a case series of 17 patients receiving PRP
application for chronic venous ulcers. This study
reported quite similar outcomes to that of ours; a
mean percentage improvement of 94.7  11.12% in
wound area and 95.6  10.19 in wound volume within
a mean of 5.1  3.1 weeks. Taken together, further
study is warranted to clearly establish the efficacy of
the PRP application in management of VLUs since
this therapy seems promising especially in regard to
providing a faster recovery, which may overcome the
concerns about its cost.
This was case series reporting our institutional
results and had several limitations. Small sample size
and selection of patients limits generalization of our
results. Single institution setting and lack of a control
group were among important major limitations with
the latter may imply the possibility of placebo effect.
Therefore, results of our study await confirmation by a
randomized controlled trial. Also, since patients with
deep venous reflux of any degree including severe
reflux were not excluded, our results regarding the
wound healing status might have been biased because
of the confounding contribution of the underlying dis-
ease onto wound healing process. Because the patients
in this study did not receive PRP therapy in equal
number of sessions but rather some completed the
treatment earlier than some others, a repeated measures
linear ANOVA test which might have provided more
accurate information was not performed.
As a conclusion, we witnessed the beneficial effects
of PRP application on wound healing process in a
selected group of VLU patients. More than half of
all patients had complete wound healing at the end
of four weeks and patients reported significant pain
relief although this may also be due to the mental
relaxation they had seeing their wound gradually
improved. The mean percentage reduction in wound
depth was slightly more prominent than that in wound
area, indicating a potential role of PRP especially in
deep venous ulcers. This finding may be leading to an
interesting object for further research as it is a well-
known fact that granulation should fill the absent
tissue before expected circumferential contraction of
the wound can occur.
Yilmaz et al.
Conflict of interest
None declared.
Funding
This study was funded by Hitit University Faculty of
Medicine, Department of Scientific Research Projects
(Project ID; TIP 19003.14.002).
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