2. MidAtlantic Vascular, LLC
Critical Limb Ischemia. P.A.D. Detection, Treatment, and Referral
Paul Sasser MD FACS
MidAtlantic Vascular, LLC

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

4. 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

5. 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?

6. 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

7. Classical Diabetic Triad of Pathology
PVD
Neuropathy
Infection

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

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

16. 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

17. 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%

18. 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

19. Endovascular Interventionalists
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

20. 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.”

21. 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

22. 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”

23. 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

24. 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

25. 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..”

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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 % improved cost per procedure cost and cost per leg year saved