MidAtlantic Vascular, LLC

Critical Limb Ischemia. P.A.D. Detection, Treatment, and ReferralCritical Limb Ischemia. P.A.D. Detection, Treatment, and Referral

Paul Sasser MD FACS Paul Sasser MD FACS

P.A.D. and PodiatryP.A.D. and Podiatry

• Podiatrists are positioned to:• Recognize the early and

advanced signs of P.A.D.

• Improve lower limb wound healing rates

• Reduce lower limb amputation rates

• P.A.D. is routinely seen in the daily practice of podiatrists

• The feet can reveal the first signs and symptoms of P.A.D.

“Podiatric physicians are commonly the first to thoroughly evaluate a

patient’s legs and feet regardless of the patient’s reason for a visit.”

Clinical Signs of Limb Ischemia

• Nonhealing wounds

• Shiny skin

• Loss of hair growth

• Cool skin temperature for one limb but not the other

• Pale or bluish skin

• Reduced capillary fill times

• Pallor on elevation and rubor on dependency

Patient presents with Critical Limb Ischemia- What do we do next?

We know our complex patients can have multiple comorbidities with similar and often overlapping signs & symptoms

Are we looking for all contributing factors?

Foot Care and P.A.D.

• Preventative foot care:• Daily foot inspection• Skin cleansing and moisturizing• Appropriate footwear• Promptly address skin lesions and

ulcers • Podiatric care

• To reduce the risk of ulcers, infection, necrosis, and amputation, high-risk patients should:

• Perform proper foot care

Receive annual foot exams

Classical Diabetic Triad of PathologyClassical Diabetic Triad of Pathology

PVD

InfectionNeuropathy

Diabetic Foot and P.A.D.

• Diabetic foot ulcers:

• 15%-25% of persons with diabetes develop a foot ulcer

• 14%-24% of persons with a foot ulcer require amputation

• Foot ulcers precede 85% of non-traumatic amputations

• About 50% of all foot ulcers are due to P.A.D.

• Peripheral neuropathy can accompany P.A.D. in patients with diabetes and lead to:

• Decreased pain perception• Sudden ulcer formation

Multidisciplinary Care of the Diabetic Foot

• A joint statement from the Society for Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA) specifies that diabetic foot care requires:

• Vascular assessment and revascularization, if necessary

• Wound assessment and staging/grading of ischemia and infection

• Risk monitoring and reduction for reulceration and infection

Limb Ischemia and the Diabetic Foot

• Critical limb ischemia (CLI) in the

diabetic population requires

multidisciplinary care

• Ischemia is one of many factors

underlying diabetic foot disease, and

leads to:

• Decreased tissue resilience

• Impeded wound healing

• Rapid tissue necrosis

• Left untreated, CLI results in non-

healing wounds and potential

amputation

Classical Diabetic Foot Treatment Plan

Stop Smoking

Exercise

Achieve Ideal Body Weight

Control Blood Pressure

Control Diabetes

Antiplatelet Therapy

Off-Loading

Debridement

Infection Management

Ischemia Management

Control Cholesterol and Triglycerides

Wound Care and P.A.D.

• P.A.D. is associated with ulcers that heal slowly or not at all

• Ulcer management:• Local wound

care/debridement• Infection control• Offloading• Revascularization• Limb salvage procedures

• Healing requires increasing perfusion beyond the level required for healthy skin

P.A.D. and infection lead to a 90 times higher risk of amputation

Guidelines on Wound Care

• A consensus panel on treating neuropathic diabetic foot ulcers recommends:

• Vascular evaluation• Palpate pulses and take

ABI and/or TBI• If P.A.D. is suspected,

refer for segmental pressure volume, skin perfusion pressure (SPP), and transcutaneous oxygen (TCPO2) measurements

• If revascularization is considered, refer for vascular consult and angiography

Guidelines on Wound Care• Consensus recommendations

include P.A.D. management for the treatment of diabetic foot ulcers

• As part of P.A.D. management, endovascular revascularization is being used increasingly in:

• Ulcer healing• Below-the-knee P.A.D.• Small vessels

• Revascularization is central to wound care and contributes to healing in 90% of patients that receive it expeditiously

Vascular Medical Specialists have long believed in the importance of treating the Whole

patient and not just the Hole in the patient

Early Detection of P.A.D. and Disease Outcomes

The major goals of early detection are to slow or stop P.A.D. progression to the more advanced stages AND to reduce cardiovascular morbidity and mortality

CLI is a Marker for DeathCLI is a Marker for Death

• Within three months of presentation CLI: Death in 9% MI in 1% Stroke in 1% Amputation in 12%

• 1-year Mortality: 21.0%• 2-year mortality: 31.6%

A Big Problem: Lesion AssessmentA Big Problem: Lesion Assessment• Less than half of the patients that eventually received

a PRIMARY amputation (49%) had any diagnostic evaluation prior to their amputation!

• Not even a simple ABI

Must go beyond PAD AssessmentsMust go beyond PAD Assessments::•Vascular history

• Physical Examination• Non-invasive vascular

laboratory• Access pulses• Arteriography

Appropriate Route for Limb Salvage

DPM Gatekeeper

Endovascular Interventionalists

• ABI• Arterial Duplex Scanning• Venous Duplex Scanning with

appropriate technologist

• Contrast Angiography• Endovascular intervention• RF Closure• Surgical Bypass• Amputation only if needed

Podiatry and P.A.D.

Case Study:• Patient presented with a foot ulcer• Podiatrist prescribed antibiotics

and requested a 2-week follow-up• At follow-up, patient was referred

for a vascular consult 17 days later• Prior to consult, patient developed

a necrotic foot• Below-the-knee amputation was

performed one month after consult• Jury awarded patient $1.23 million

for not receiving a prompt vascular referral

“Medical-legally, we also find ourselves in the position where recognition of

P.A.D. and pro-active intervention will not only be expected, but also

necessary for better risk management.”

Prognosis & Economic Impact of CLI

• Critical Limb Ischemia (CLI) is defined as extremity pain at rest or as impending tissue loss that is caused by a severe compromise of blood flow.

• DX of CLI should be confirmed by ankle-brachial index (ABI) :

• Ischemic rest pain most commonly occurs below an ankle pressure of 50mm HG or a toe pressure less than 30 mm Revascularization is central to wound care and contributes to healing in 90% of patients that receive it expeditiously

P.A.D. Evaluation

• P.A.D Patients:• 80% are current or former

smokers• Diabetes is associated

with a 21% risk of amputation as compared with 3% in nondiabetic patients

• Traditional cardiovascular risk factors also play a lesser role: males, age, black race, & hypertension.

“Remarkably a recent study showed that only 35% of patients undergoing limb

amputation in the U.S. had an ABI documented and only 16% of amputees

underwent peripheral angiography”