Transcript available now #9 - Grand Strand Advanced Practice Nurse Association

Critical Limb Ischemia. P.A.D.
Detection, Treatment, and
Referral
Paul Sasser MD FACS
MidAtlantic Vascular, LLC
P.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
“Podiatric physicians are commonly
the first to thoroughly evaluate a
patient’s legs and feet regardless of
the patient’s reason for a visit.”
• 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.
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 IschemiaWhat 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 Pathology
PVD
Neuropathy
Infection
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 nonhealing 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. and infection lead to a 90
times higher risk of amputation
• 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
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 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 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 Assessments:
•Vascular history
• Physical Examination
• Non-invasive vascular laboratory
• Access pulses
•
Arteriography
Appropriate Route for Limb Salvage
• ABI
• Arterial Duplex Scanning
• Venous Duplex Scanning with
appropriate technologist
•
•
•
•
•
Contrast Angiography
Endovascular intervention
RF Closure
Surgical Bypass
Amputation only if needed
DPM Gatekeeper
Endovascular
Interventionalists
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
“Medical-legally, we also find ourselves
• Jury awarded patient $1.23 million
in the position where recognition of
for not receiving a prompt vascular
P.A.D. and pro-active intervention will
referral
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 anklebrachial 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
“Remarkably a recent study showed that
risk factors also play a
only 35% of patients undergoing limb
lesser role: males, age,
amputation in the U.S. had an ABI
documented and only 16% of amputees
black race, &
underwent peripheral angiography”
hypertension.
Clinical Presentation P.A.D.
• Physical Examination:
 Dry skin, thickened nails,
loss of hair.
 Coolness to palpation
 Decreased or absent pulses
 Pallor or dependent rubor
 Nonhealing wound or ulcer,
especially over bony
prominences, and on the
plantar surface of the
Clinical Presentation P.A.D.
• Noninvasive Vascular Laboratory:
 Ankle-Brachial index < 0.4 or >
1.3
 Ankle systolic pressure < 50
mm Hg
 Toe systolic pressure < 30 mm
Hg
 Transcutaneous oxygen
tension < 10 mm HG
CLI “Rule of ¼”
• For patients with Critical
Limb Ischemia, after one
year :
 ¼ Resolution
 ¼ Ongoing
 ¼ Require amputation
“One-year CLI outcomes could
 ¼ Dead
approximate the following onefourth rule..”
Be a Proactive Part of the Solution
• A program to promote:
 Early identification and diagnosis of CLI by
podiatrists
 Followed by prompt referral to endovascular
specialists in your patients’ communities
 Completed by aggressive wound care and
surveillance programs by the health care
partners
LE Amputation
• Impact:
 Devastating psychological
and quality of life issues
 Survival Perioperative
mortality – BKA 5-10% –
AKA 15-20%
 Second amputation required
in 30% of cases.
 Full mobility achieved in 50%
of BKA & 25% of AKA
LE Amputation
• Impact:
 It is estimated
that between
220,000 and
240,000 major
and minor lower
extremity
amputations are
performed for
CLI in the US and
Europe annually
Charleston West Virginia, Population 240K
LE Amputation
• LE Amputation Rate:
 Despite advances in
medical and
interventional
therapies, the
amputation rate has
increased from 19 to
30 per 100,000
person/year over
the past 2 decades
 Mainly driven by an
increase in diabetes
and aging patient
populations
LE Amputation
• Success of Rehabilitation:
 Below Knee Amputation
(BKA) less than two
thirds
 Above Knee Amputation
(AKA) less than one half
 Fewer than 50% of
amputees ever achieve
full mobility
CLI Economic Impact
• Expenses, difficult to
assess in costeffectiveness analysis:
 Home Health Aids
 Construction &
adaptation of home
 Influence on family
 Productivity
economics
 Long-term health
care costs
CLI Economic Impact- First Line Treatment
• Recent cost-effectiveness
analysis of US Medicare patients
– First line treatment:
 67% Primary Amputation
 23% Surgical
Revascularization
 10% Percutaneous
Revascularization
 Amputation seems to be
over utilized despite being
associated with worse
patient outcome.
CLI Economic Impact
Surgical Revascularization
• Surgical revascularization for
limb salvage:
 34% increase in 5-year
survival
 Primary amputation three
times more costly than
surgical revascularization
in both diabetic and non
diabetic patients
 Percutaneous
revascularization offers
30-50% improved cost per
procedure cost and cost
per leg year saved
Contrast Angiography
• Identifies the level of arterial
disease such that
endovascular and/or surgical
interventions can be planned
appropriately
• Endovascular therapy, such as
atherectomy, angioplasty,
and/or stenting, can be
performed during contrast
angiography, if warranted.
Endovascular Therapy- PTA
• Percutaneous Transluminal
Angioplasty (PTA)
 Is the initial therapy of
choice for CLI in patients
who are candidates for
either surgery or
endovascular therapy
 Avoids the additional
morbidity associated with
vascular surgery
 Does not preclude the
possibility of subsequent
surgery
Bypass Versus Angioplasty in
Severe Ischemia of the Leg
BASIL (2005) study of
452 patients
– Shows that
endovascular therapy
and surgery were
comparable as first-line
therapies for CLI but that
PTA was less expensive
and did not preclude
subsequent treatment
with surgery
Infrapopliteal PTA
• Two recent trials have
shown the efficacy and
attractiveness of an initial
percutaneous approach for
patients with CLI and
infrapopliteal vascular
disease :
 90% limb salvage after
2-5 years
 Suggests angioplasty of
the tib-peroneal trunk
should not be reserved
just for limb-salvage
Endovascular Therapy
• Atherectomy
 A minimally invasive
technique for removing
atherosclerosis from a
blood vessel
 The advantage of
atherectomy over
angioplasty is that it
removes plaque. It
reduces the amount of
barotrauma on the vessel
wall.
Vascular Surgery, Podiatric Medicine & Primary Care
practices are loaded with Chronic Venous
Insufficiency among the Patients we serve
Vascular diseases of the periphery can be the marker for overall
cardiovascular events involving the coronary, renal and cerebral
arteries, as well as the superficial venous system
Another Solution:
Dietary Habits
Supersizing
Diabesity –
Work in
Progress
Better
End Result
This critical gatekeeper position presents an opportunity for
the Podiatric Medicine Specialist & Primary Care Physician
to identify potential or actual life-threatening diseases,
before otherwise clinically
evident to patients or other
health care providers
As a Vascular Surgeon, I can treat the entire cascade
of arterial or venous problems
Many of your patients with skin
changes, swelling and leg pain may
be candidates for procedures such
as closure, atherectomy, stenting,
angioplasty and/or bypass
Please join me to institute relationships with your
colleagues who are the Vascular Interventionalists
MidAtlantic Vascular
Associates in Surgery
Sasser Ellis Epstein Rimkus
Borowicz Moore
Call to Action for Podiatrists & Primary Providers
1. Use medical history and
recognize P.A.D. risk factors
2. Take ABI measurements for
high-risk patients
3. Provide proper wound care
4. Aggressively and promptly treat
risk factors or refer patients for
risk reduction treatment
5. Make appropriate referrals to
restore blood flow
Our Patients deserve our best collaborative &
comprehensive expertise
Total team care is imperative to have a concerted effort
to promote a positive effect and avoid a potential
catastrophe
Each stage of the management, from presentation
of the problem until resolution, necessitates
continuous communication and cooperation
among:
Primary
Care
Physician
Podiatric
Medicine
Specialist
Vascular Interventionalist
Know When To Punt!
Our Patients
deserve our
collaborative
efforts
CLI – Conclusions
Bibliography
1) Bell (2009); APMA (2008); Sanders (2005)
2) Hirsch et al. (2006) ACC/AHA Practice Guidelines for PAD; Norgren et al. (2007) TASC II
Guidelines for PAD
3) Hirsch et al. (2006) ACC/AHA Practice Guidelines for PAD; Norgren et al.
(2007) TASC
II Guidelines for PAD; Bell (2009)
4) Norgren et al. (2007) TASC II Guidelines for PAD; Bevilacqua et al. (2010); Sumpio et al.
(2010)
5) Sumpio et al. (2010)
6) Janov (2007); Bell (2009)
7) Allie (2005) , Ouriel (2001), Ruffolo (2010)
8) Soder (2000) Dorros (2001)