2nd symposium Presentation May 2015

2nd IVT-Symposium in Frankfurt, Germany (30.05.2015)

IVT on diabetic macro-angiopathy

Dr. rer. nat. Bernd StratmannHerz- und Diabeteszentrum NRWUK RUB32545 Bad Oeynhausen

seit 1984


THE MEDICAL PROBLEM

PAD = peripheral arterial (obstructive) diseasechronic atherosclerotic process

narrowing of peripheral arterial vasculaturepredominantly affecting lower limb

Prevalence ~10%, ~30% in patients 50 years

critical limb ischemia (CLI) = most severe manifestationresults in limb loss, multimorbidity, death

Risk factors : smoking, diabetes, hypertension, dyslipoproteinemia

definition is typically clinical/observational as patients presenting with true ischemic rest pain,non-healing ischemic ulcers, or gangrene

PAD = independent predictor of limb loss

seit 1984


Stage acc. Fontaine

Symptoms

I Asymptomatic

IIa Pain free walking distance > 200m

IIb Pain free walking distance < 200m

III Ischemic rest pain

IV Ulceration, gangrene

THE MEDICAL PROBLEM PAD CLASSES

seit 1984


DIABETES MELLITUS + PAD

- 4fold increase of manifestations- ealier stage- progress is more rapid

Outcome after surgical revascularisation is worse,mainly due to delayed diagnosis

10-16fold increase to undergo major amputation50% of patients die within 2 years after MA

>85% of major amputations in patients with diabetes are preceded by foot ulceration (PAD and DNP (and mixed types) as equivalent causes)

seit 1984


seit 1984

getABI Situationin Germany

Diehm C et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study.Atherosclerosis. 2004 Jan;172(1):95-105.

http://allgemeinmedizin-simsch.com

seit 1984



Only 1 in 10 of these patients has classical

symptoms of intermittent claudication (IC)

1 in 5 people over 65has PAD

ABI

seit 1984



seit 1984


THE SOLUTION = INCREASE FLOW!

seit 1984


CASES TO TREAT

89year old female patient (T2DM, DFS (W/A3D), PAD(IV), CAD, AF (pacemaker), Hypertension, Dyslipoproteinemia, renal insufficieny G3A1)

represents a multimorbid, palliative setting, no vascular revascularisation/catheterisation possible

TcPO2 before and after IVT 4-phase-programme (accelerating time and vacuum up to -30 mbar)6 therapeutic sessions

seit 1984


BEFORE TcPO2left: 12 bzw. 18 mmHgright: 9 bzw. 4 mmHg

AFTER TcPO2left: 25 bzw. 45 mmHgright: 29 mmHg

seit 1984


CASES TO TREAT

72year old male patient (T1DM, DFS (W/A1C), PAD(IV), CAVK, AF, Retinopathy, DPN, Hypertension, Dyslipoproteinemia, renal insufficieny G3)



seit 1984


BEFORE TcPO2left: 25 bzw. 30 mmHgright: 15 bzw. 17 mmHg

AFTER TcPO2left: 35 bzw. 40 mmHgright: 20 bzw. 25 mmHg

seit 1984


CASES TO TREAT

68year old male patient (T2DM, DFS (W/A1C), PAD(IV), CAVK, CAD, AF, Retinopathy, DPN, Hypertension, Dyslipoproteinemia, renal insufficieny G3)



seit 1984


BEFORE TcPO2left: 10, 50, 60 mmHgright: 33 mmHg

AFTER TcPO2left: 50 bzw. 55 mmHgright: 35 mmHg

Directly after : successful aortic valve replacement

seit 1984


CASES TO TREAT

75year old male patient (T2DM, DFS (W/A3D, W/A4D), PAD(IV), CAD, AF, Retinopathy, DPN, Hypertension, Dyslipoproteinemia)



seit 1984


BEFORE TcPO2left: 35 mmHgright: 13, 27, 27 mmHg

AFTER TcPO2left: 45 mmHgright: 20, 20, 30 mmHg

seit 1984


Screening1 Therapeutic phase(unblinded) EOS2

6 cycles

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15(EOS) EOS Study day

R=RandomisationEOS= end of Study1 Screening: ABI, TcPO22 EOS: ABI, TcPO2

28 Patients-10 mbar

28 Patients-50 mbar

Primary objective: qualitative improvement in perfusion

Secondary objective: quantitative improvement ABI, TcPO2, QoL, relief of pain

The observational, randomized study

seit 1984


Key inclusion criteria

T1DM, T2DM PAD II-IV TcPO2 25 mmHg 18 to 80 years of age

Key exclusion criteria

Heart failure NYHAII-IV Dialysis on same day Phlebothrombosis PTA/PTCA/Bypass during therapy iliac artery occlusion Pregnancy

=> Results to be awaited next year


Herz- und Diabeteszentrum NRW, Bad Oeynhausen | www.hdz-nrw.de

~ 60.000 amputations per year

Strong demand for alternative concepts

Blood flow provides peripherywith oxygen and nutrients

Lymphatic Lymphatic

Microsurgery and Microsurgery and

IIntermittent ntermittent SSuction uction

TTherapy (Vacumed) for herapy (Vacumed) for

LymphedemaLymphedema

C. Campisi, F. Boccardo, C.C. CampisiDepartment of Surgery

Section of Lymphology & MicrosurgeryOperative Unit of Lymphatic Surgery

Operative Unit of Plastic & Reconstructive SurgeryIRCCS University Hospital San Martino - IST

National Institute for Cancer ResearchGenoa, Italy

[email protected]

TThe Pioneer Tosattihe Pioneer Tosattis Devices Device: Genova, 1967!: Genova, 1967!NEGATIVE PRESSURE SUCTION THERAPYNEGATIVE PRESSURE SUCTION THERAPY

HYPERBARIC OXYGEN THERAPYHYPERBARIC OXYGEN THERAPY

Designed for NASA...Designed for NASA...

Lower Body Negative Pressure Device (LBNPD)Developed for manned space missions in the 1960s

Designed to ensure the perfusion of lower limbs in orbit

Fortney, S.M. Development of lower body negative pressure as a countermeasure for

orthostatic intolerance. J Clin Pharmacol 1991; 31:888-92.

Developed for health professionals...Developed for health professionals...

AOD casesAOD cases

Straminski et al. Result of clinical examination., Praxis Kln., 2001

Arthroscopic meniscus repairsArthroscopic meniscus repairs

Orlietzky, A. ., Timtchenko, D. O. Use of devices for intermittent negative pressure therapy for

treatment of athletes., Moscow, 2009

Intermittent pressureIntermittent pressure

Fluctuates between phases of negative and positive (normal) pressure

Negative PressureNegative Pressure

Triggers the movement of circulating blood volume

into lower extremities and abdomen

Reduction of blood pressure in the central vein and

heartbeat volume

Compensatory mechanisms: increase in pulse rate

and peripheral vessel resistance, activation of

sympathetic response such as catecholamine

secretion

Increase in amount of oxygenized and deoxygenized

haemoglobin in muscles of lower extremities

Gasiorowska et al. Cardiovascular and neurohormonal responses to lower body negative pressure

(LBNP): effect of training and 3 day bed rest. J Physiol Pharmacol 2006; 57:85-100

Hisdal et al. Onset of mild lower body negative pressure induces transient change in mean arterial

pressure in humans. Eur J Appl Physiol., 2002; 87:251256.

Positive PressurePositive Pressure

Return to normal heart beat volume

Venous blood and lymph move into larger vessels

(increased backflow)

Accelerated micro-perfusion and lymphatic

drainage

pH increase strengthen connective tissue by

increasing collagen synthesis

Lathers et al. Use of lower body negative pressure to assess changes in heart rate

response to orthostatic-like stress during 17 weeks of bed rest. J Clin Pharmacol. 1994;

34:563-70.

Goswami et al. LBNP: past protocols and technical considerations for experimental

design. Aviat Space Environ Med. 2008; 79:459-71.

For Lymphatic Disorders?For Lymphatic Disorders?

Reduction of oedema

Increased microperfusion in lower extremitiesArterial and venous properties altered in lymphedemous limbs:

Lower venous tone

Slower venous return

Increased arterial blood flow into lymphedemous limb

Increased collagen synthesis & strengthened connective tissue Reduction of cellulite in obesity with intermittent pressure therapy

Due to improved lymph flow and skin tone

Useful for Lymphedema and Lipoedema patients

Montgomery et al. Segmental bloodflow and hemodynamic state of lymphedematous and

nonlymphedematous arms. Lymphat Res Biol 2011; 9:31-42

Loberbauer-Purer et al. Can alternating lower body negative and positive pressure during exercise alter

regional body fat distribution or skin appearance? Eur J Appl Physiol 2012; 112:1861-1871

For Lymphatic Disorders?For Lymphatic Disorders?

YES

As part of a complete

therapy regimen (CLyFT)

In combination with

Lymphatic Microsurgery

Staging of Staging of Lymphedema (Lymphedema (ISL ISL -- SIL SIL -- ICFICF))

Clinical Lymphoscintigraphic Criteria

Immunohistochemical Criteria

Disability Grading

33

33

44

Staging of LymphedemaStaging of Lymphedema

STAGE I

STAGE II

STAGE III

A. "LatentLymphedema, without clinical evidence of edema, but with

impaired lymph transport capacity (provable by lymphoscintigraphy) and with initial immuno-histochemical alterations of lymph nodes, lymph vessels and extracellular matrix.

A. Increasing

B. Column-shaped

B. Extreme Elephantiasis

B. InitialLymphedema, totally or partially decreasing by rest and draining

position, with worsening impairment of lymph transport capacity and immuno-histochemical alterations of lymph collectors, nodes and extracellular matrix.

A. Elephantiasis

STAGE I

STAGE II

STAGE III

A. "Latent

A. Increasing

B. Column-shaped


B. Initial

A. Elephantiasis

Lymphedema, with vanishing lymph transport capacity, relapsing lymphangitic attacks, fibroindurative skin changes and developing disability.

Limb Fibrolymphedema, characterized by lymphostatic skin changes, suppressed lymph transport capacity and worsening disability


STAGE III

A. "Latent

A. Increasing

B. Column-shaped


B. Initial

A. ElephantiasisProperly called Elephantiasis, with scleroindurative pachydermitis,

papillomatous lymphostatic verrucosis, no lymph transport capacity and life-threatening disability

With total disability

STAGE I

STAGE II


Stage I

Stage II

Stage III

Staging of Staging of Lymph Vessel ImpairmentLymph Vessel Impairment

Stage I

Stage II

Stage III

Staging of Staging of Lymph Nodal ImpairmentLymph Nodal Impairment

An Unexpected RoleAn Unexpected Role

Interstitial MatrixInterstitial Matrix

CPT alone? When?

Micro alone? When?

CPT + Micro? When?

A frequent questionA frequent question Not a predictable Not a predictable answeranswer

CPT6-12 Months

Microsurgery1 week

Post-op RehabFU (3-5 years)

CLyFTCLyFT with with VACUMEDVACUMED Therapy Therapy for for LYMPHEDEMALYMPHEDEMA

Microsurgical Treatment of Microsurgical Treatment of LymphedemaLymphedema

Kinds of Lymphedemas suitable for treatment with Microsurgery: Primary obstructive arm and leg lymphedemas Secondary arm and leg lymphedemas Unilateral lymphedemas Bilateral lymphedemas Ideal indication: IB - IIA stage lymphedemas Good results also for IIB - III stage lymphedemas

Lymphatic MicrosurgeryLymphatic Microsurgery

LVALymphatic Venous

Anastomoses

LVLALymphatic Venous

Lymphatic Anastomoses

Multiple LVAMultiple LVA

External Venous Valve PlastyExternal Venous Valve Plasty

19731973--2011 2011 24872487 Cases Treated by Microsurgery Cases Treated by Microsurgery LVA / LVLA (FU 5LVA / LVLA (FU 5--15 Years)15 Years)


P < 0.01

Stages of Lymphedema Treated by MicrosurgeryStages of Lymphedema Treated by Microsurgery(1973(1973--2011)2011)

Reconstructive LVLAReconstructive LVLA

Postop. After >20 years Preop.

Reconstructive LVLAReconstructive LVLA


Post-operative Treatments

Antibiotics (preoperative short-term therapy and, after, long-acting penicillin for 1-2 years). LMWH, for the first 3 days post-op and then, aspirin 100-150 mg. for 6-12 months. Functional multilayer bandages are applied for the first week and, afterwards, proper elastic supports (stockings, sleeves, etc.) for at least 3-5 years, allowing the patient to progressively give up the use of these compression garments after the first 1-3 years, depending on lymphedema stage

Adjuvant Treatments

Mechanical intensive lymphatic drainagefor the two weeks preceding the week of hospitalization for the surgical operation. Post-operatively: manual lymph drainagefor the first 3-5 days and, then, low mechanical lymph drainage for another week.The follow-up consists of periodic clinical assessments (volumetry, measurements of circumferences, etc.) and instrumental evaluations (by lymphoscintigraphy).


Some of our clinical casuistrySome of our clinical casuistry

Postop. Preop.

Postop.

Postop. Preop.

Preop.Preop.

Postop.Postop.

Postop. Preop.

Preop.Postop.

Preop.Preop.

Postop. Postop.

Preop.Preop.

Postop.Postop.

Preop.Preop.

Postop. Postop.

Preop.Preop.

Postop. Postop.


P < 0.01

Lymphatic Microsurgery Lymphatic Microsurgery combined with combined with Intermittent Suction Intermittent Suction

Therapy (VacumedTherapy (Vacumed) have highly significant results for an ) have highly significant results for an

effective and longeffective and long--term treatment of Peripheral term treatment of Peripheral

LymphedemaLymphedema

Surgery and Translational LymphologySurgery and Translational Lymphology

Infections Traumas

Chylife-rous vessels

Cisterna chyli

Thoracic duct

Tumors

Prevention

Primary and Secondary Prevention of Primary and Secondary Prevention of Lymphatic LesionsLymphatic Lesions

Urological Surgery

Plastic and Reconstructive Surgery General

Surgery

Gyneco-logical Surgery

Vascular Surgery

Latest Main References Latest Main References

1. Dellach A, Boccardo F, Zilli A, Napoli F, Fulcheri E, Campisi C. Unexpected Histopathological Findings in Peripheral Lymphedema. Lymphology 2000;33(Suppl):62-64.

2. Bellini C, Boccardo F, Campisi C, Villa G, Taddei G, Traggiai C, Bonioli E. Lymphatic dysplasias in newborns and children: the role of lymphoscintigraphy. J Pediatr. 2008 Apr;152(4):587-9.

3. Boccardo F, Bellini C, Eretta C, Pertile D, Da Rin E, Benatti E, Campisi M, Talamo G, Macci A, Campisi C, Bonioli E, Campisi C. The lymphatics in the pathophysiology of thoracic and abdominal surgical pathology: immunological consequences and the unexpected role of microsurgery. Microsurgery 2007;27(4):339-45.

4. Campisi C, Bellini C,Eretta C, Zilli A, Da Rin E, Davini, Bonioli E, Boccardo F. Diagnosis and management of primary chylous ascites. J Vasc Surg. 2006 Jun;43(6):1244-8.

5. Campisi C, Da Rin E, Bellini C, Bonioli E, Boccardo F. Pediatric lymphedema and correlated syndromes: role of microsurgery. Microsurgery 2008;28(2):138-42.

6. Campisi C, Boccardo F. Vein graft interposition in treating peripheral lymphoedemas. Handchir Mikrochir Plast Chir. 2003 Jul;35(4):221-4.

7. Campisi C, Boccardo F. Microsurgical techniques for lymphedema treatment: derivative lymphatic-venous microsurgery. World J Surg. 2004 Jun;28(6):609-13.

8. Campisi C, Eretta C, Pertile D, Da Rin E, Campisi C, Macci A, Campisi M, Accogli S, Bellini C, Bonioli E, Boccardo F. Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives. Microsurgery 2007;27(4):333-8;

9. Boccardo F, Bellini C, Eretta C, Pertile D, Da Rin E, Benatti E, Campisi M, Talamo G, Macci A, Campisi C, Bonioli E, Campisi C. The lymphatics in the pathophysiology of thoracic and abdominal surgical pathology: immunological consequences and the unexpected role of microsurgery. Microsurgery 2007;27(4):339-45.

10.Pardini M, Bonzano L, Roccatagliata L, Boccardo F., Mancardi G, Campisi C. Functional magnetic resonance evidence of cortical alterations in a case of reversible congenital lymphedema of the lower limb: a pilot study. Lymphology 2007 Mar;40(1):19-25.

11.Gloviczki P. Handbook of Venous Disorders. Third Edition. Guidelines of the American Venous Forum. Edward Arnold Publ. 2009;658-672.

12.Boccardo F, Casabona F, De Cian F, Friedman D, Villa G, Bogliolo S, Ferrero S, Murelli F, Campisi C. Lymphedema microsurgical preventive healing approach: a new technique for primary prevention of arm lymphedema after mastectomy. Ann Surg Oncol 2009.

13.Boccardo F, Bellini C, Girino M, Campisi C, Vidali F, Corazza GR, Campisi C. Diagnostic assessment and therapeutic approach for immunodeficiency due to chylous dysplasia: a case report. Microsurgery 2010 Jul;30(5):401-4.

14.Boccardo F, Campisi C, Murdaca G, Benatti E, Boccardo C, Puppo F, Campisi C. Prevention of lymphatic injuries in surgery. Microsurgery 2010 May;30(4):261-5.

15.Campisi C, Bellini C, Campisi C, Accogli S, Bonioli E, Boccardo F. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery 2010 May;30(4):256-60.

16.Suami H, Chang DW. Overview of surgical treatments for breast cancer-related lymphedema. Plastic and Reconstructive Surgery Journal 2010 Dec;126(6):1853-63.

17.Boccardo F, Casabona F, Friedman D, Puglisi M, De Cian F, Ansaldi F, Campisi C. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol 2011.

18.Witte MH, Dellinger MT, McDonald DM, Nathanson SD, Boccardo FM, Campisi CC, Sleeman JP, Gershenwald JE. Lymphangiogenesis and hemangiogenesis: potential targets for therapy. J Surg Oncol. 2011 May;103(6):489-500.

19.Campisi C, Witte MH, Fulcheri E, Campisi C, Bellini C, Villa G, Campisi C, Santi PL, Parodi A, Murdaca G, Puppo F, Boccardo F. General Surgery, translational lymphology and lymphatic surgery. International Angiology 2011;30(6):504-521.


20. Campisi C, Campisi C, Boccardo F. Topics in cancer survivorship. Chapter 4 (pp. 43-52), Surgical prevention of arm lymphedema in breast cancer treatment. InTech Publisher, January 2012.

21. Campisi CC, Spinaci S, Lavagno R, Larcher L, Boccardo F, Santi PL, Campisi C. Immunodeficiency due to chylous dysplasia: diagnostic and therapeutic considerations. Lymphology 2012 Jun; 45(2):58-62.22. Boccardo F, Campisi CC, Molinari L, Dessalvi S, Santi PL, Campisi C. Lymphatic complications in surgery: possibility of prevention and therapeutic options. Updates Surg. 2012 Sep.;64(3):211-6. Epub 2012 Jul. 21.23. Campisi CC, Larcher L, Lavagno R, Spinaci S, Adami M, Boccardo F, Santi PL, Campisi C. Microsurgical primary prevention of lymphatic injuries following breast cancer treatment. Plast Reconstr Surg 2012 Nov;130(5):749e-750e.24. Boccardo F, Fulcheri E, Villa G, Molinari L, Campisi C, Dessalvi S, Murdaca G, Campisi C, Santi PL, Parodi A, Puppo F, Campisi C. Lymphatic microsurgery to treat lymphedema: techniques and indications for better results. Ann Plast Surg 2012 (in press).25. Fulcheri E, Pacella E, Ceriolo P, Campisi C, Boccardo F, Campisi C. A new classification to define primary dysplastic lymphedemas. Lymphology 2012 (in press).


Le Giornate Genovesi della Chirurgia ItalianaLe Giornate Genovesi della Chirurgia ItalianaGENOA, ITALYGENOA, ITALY

24th June 2013 Opening

25-26-27 June 2013 Joint Congress

THE USE OF IVT IN A WOUND CARE PRACTICE

Liezl Naude

Wound Management SpecialistBCur, MCur, Cert Wound Care (UFS), Cert Wound Care

(Hertfordshire), IIWCC (SUN/Toronto)

L NAUDE WEYERGANS GERMANY 2015 2

WOUND MANAGEMENT INNOVATIONEstablished 2000

Holistic patient centred approach

Multidisciplinary team

Focussed on lower limb management

Specialised diagnostic tests and screening methods

IVT


ELOQUENT LEARNING HEALTHEstablished 2005

Practical hands on training

Evidence based practice

Multidisciplinary team

Short courses

Symposiums

Conferencing


ELOQUENT WELLNESS

Early diagnostics Optimising wellbeing

and healing

Rehabilitation


PATIENT PROFILE

Diabetes Venous leg ulcers Arterial insufficiency Post op surgery Lymphoedema


BASELINE TREATMENT PROTOCOL

Medical history

Current problem

Patient Centred concerns

Vascular status

Leg Measurement

Saturation rate

Wound Assessment

Pain assessment

Program according to individual needs of the

patient

Evaluate weekly:

Leg circumference

Wound size

Wound bed

Pain

Saturation levels

Epidemiology involved

i.e. Diabetes,

Cardiovascular disease

ABPI & palpable

pulses

Capillary refill

Ankle, calf and thigh

measurement

Saturation %

Photograph with ruler

Longest width x

longest length

Pain scale 0-10IVT and

Wound management

If improvement not as

expected re-assess

the patient

IF ABPI LESS THAN

0.6 PATIENT IS FIRST

REFERRED TO

VASCULAR SURGEON

BEFORE

COMMENCING

TREATMENT


CASE EXAMPLES


PATIENT WITH CHRONIC VENOUS HYPERTENSION WITH LYMPHATIC COMPONENT FOR 6 YEARS.

Session 1R leg Thigh = 48, calf =39,5cm, Ankle = 28,5cm

L Leg Thigh =47, calf 48cm, ankle = 30.5cm

Session 5R leg Thigh = 45, calf =34,5cm, Ankle = 24cm

L Leg Thigh =45, calf 36.5cm, ankle = 26.5cm

Oxygen saturation %

88% - 92%

Oxygen saturation %

90% - 94%


PATIENT WITH 7 YEAR HISTORY OF CHRONIC LYMPHOEDEMA AND ECZEMA

Session 1


SESSION 1 SESSION 12

PATIENT WITH CHRONIC ULCERATION AND OEDEMA3 YEAR ULCER HISTORY

Session 1R leg, calf =46cm, Ankle = 23cm

L Leg, calf 48cm, ankle = 25cm

Session 12R leg, calf =41cm, Ankle = 21cm

L Leg calf 42cm, ankle = 21.5cm

Oxygen saturation %

86% - 90%

Oxygen saturation %

92% - 96%


DIABETES WITH LYMPHOEDEMA & MYCOSIS FUNGOIDIS

4 SEPTEMBER 2014


DIABETES WITH LYMPHOEDEMA & MYCOSIS FUNGOIDIS

DATE 17 SEPTEMBER 2014 DATE 17 NOVEMBER 2014DATE 17 OCTOBER 2014


TREATMENT PROTOCOL

TREATMENT:

1. IVT which consists of 30minute sessions with exposure to negative pressure at -38mmHg - -50mmHg.

2. 3 times per week

3. LED light therapy with biofilm remover gel for 15 minutes

4. Wound dressing

5. Modified compression bandaging

CHALLENGES:

Travel distance

Infection

Mycosis fungoides

Radiotherapy


ARTERIAL INSUFFICIENCY WITH LYMPHOEDEMA25 JULY 2014


ARTERIAL INSUFFICIENCY WITH LYMPHOEDEMA

DATE 11 AUGUST 2014 DATE 22 DECEMBER 2014DATE 29 SEPTEMBER 2014


TREATMENT PROTOCOL

TREATMENT:

1. IVT which consists of 30minute sessions with exposure to negative pressure at -38mmHg - -50mmHg.

2. 3 times per week

3. LED light therapy with biofilm remover gel for 15 minutes

4. Wound dressingAFTER 10 DAYS AND 4 IVT

SESSIONS

CHALLENGES:

Travel distance

Infection

Lymphoedema

Age

Mobility


IVT

Improved circulation

Cleaning up the dirt

Kick starting the normal

inflammatory phase

Improved tissue

regeneration in proliferation

phase

SUCKING FRESH BLOOD

INTO THE LEGS,

SQUEEZING VENOUS

BLOOD & LYMPH OUT,

PURIFYING THE TISSUE

FROM THE INSIDE

CONCLUSION

space with nothing in it

cleaning up the dirt providing a clear

pathway for healing


[email protected]

www.eloquent.co.za


Documents

2nd symposium Presentation May 2015