MidAtlantic Vascular, LLC

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MidAtlantic Vascular, LLC
Critical Limb Ischemia. P.A.D. Detection,
Treatment, and Referral Paul Sasser MD FACS
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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
• 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 patients legs and feet
regardless of the patients reason for a visit.
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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

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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?
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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

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Classical Diabetic Triad of Pathology
PVD
Infection
Neuropathy
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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

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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

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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

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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
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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
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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

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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

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Vascular Medical Specialists have long believed
in the importance of treating the Whole patient
and not just the Hole in the patient
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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
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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

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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

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Appropriate Route for Limb Salvage

• ABI
• Arterial Duplex Scanning
• Venous Duplex Scanning with appropriate
  technologist

DPM Gatekeeper

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

Endovascular Interventionalists
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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.
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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

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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
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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

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Clinical Presentation P.A.D.

• Noninvasive Vascular Laboratory
• Ankle-Brachial index lt 0.4 or gt 1.3
• Ankle systolic pressure lt 50 mm Hg
• Toe systolic pressure lt 30 mm Hg
• Transcutaneous oxygen tension lt 10 mm HG

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CLI Rule of ¼

• For patients with Critical Limb Ischemia, after
  one year
• ¼ Resolution
• ¼ Ongoing
• ¼ Require amputation
• ¼ Dead

One-year CLI outcomes could approximate the
following one-fourth rule..
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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

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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

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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
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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

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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

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CLI Economic Impact

• Expenses, difficult to assess in
  cost-effectiveness analysis
• Home Health Aids
• Construction adaptation of home
• Influence on family
• Productivity economics
• Long-term health care costs

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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.

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CLI Economic ImpactSurgical 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

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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.

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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

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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
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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

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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.

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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