1. Erin Moore Clinical Problem Solving I
Foot Pressure Ulcers: In Patients with Peripheral Vascular Disease (PVD)/ Peripheral Artery Disease (PAD)
Erin Moore
Clinical Problem Solving I

2. Clinical Question: Is peripheral vascular disease/ peripheral artery disease a valid prognostic factor for determining the healing process of foot pressure ulcers in an 80 year old man?
Is a 80 year old male with peripheral vascular disease (PVD) or peripheral artery disease (PAD) a valid prognostic factor for determining whether he will recover from pressure ulcers on their heels?

3. Patient History: Age: 81 year old Gender: Male
Admitted to Hospital: unstable BP, positive orthostatic hypotension
Orthopedic Surgeries:
L TKR in 2011, R TKR in 2015
Comorbidities:
Hypertension
Osteoarthritis of knee: Left TKR 2011
Hyponatremia
Acute blood loss anemia
Pressure Sore

4. Patient History: Prior Activity Levels to R TKR:
Independent with ambulation and ADLs
Response to previous PT
After R TKR not participating in PT at SNF
Current Medications
Warfarin (Coumadin) 4mg daily
Treats high blood pressure
Lisinopril (20 mg tablet)
Amlodipine (2.5 mg tablet)
Mechanism of Injury
Prior to admission to acute care:
R TKR
Discharged to SNF
Wounds developed in SNF:
Right dorsal foot
Right calf due ace bandage
Bilateral heel blisters
Left heel partial thickness wound

5. Initial Examination: Vitals: Day1
Position
Blood Pressure (mmHg)
Heart Rate (bpm)
Supine
114/73 92
Sitting
87/68
(Orthostatic Hypotension) 99
Sitting with LE Exercises
112/80
100
Standing
65/51 ~
123/76
Blood pressure may be effected by calcification in arteries or veins
Potential atherosclerosis could be affecting BP and vascularization in the lower extremity

6. Test and Measures: Ankle Brachial Index (ABI)
Noninvasive way to check risk for peripheral artery disease
Calculation of ABI:
Patients measured ABI:
0.49
Severe Arterial Disease
Reason patient sent to catherization lab
Right ABI= Highest SBP of arteries in Right foot
Highest SBP in both arms
ABI Value
Interpretation
Recommendation
Greater than 1.4
Calcification/Vessel Hardening
Refer to vascular specialist
Normal
None
Acceptable
Some Arterial Disease
Treat risk factors
Moderate Arterial Disease
Less than 0.5
Severe Arterial Disease
Normal ABI ranges from 1.0 — 1.4
Pressure is normally higher in the ankle than the arm.
Values above 1.4 suggest a noncompressible calcified vessel.
In diabetic or elderly patients, the limb vessels may be fibrotic or calcified. In this case, the vessel may be resistant to collapse by the blood pressure cuff, and a signal may be heard at high cuff pressures. The persistence of a signal at a high pressure in these individuals results in an artifactually elevated blood pressure value.
An value below 0.9 is considered diagnostic of PAD.
Values less than 0.5 suggests severe PAD.
Individuals with such severe disease may not have sufficient blood flow to heal a fracture or surgical wound; they should be considered for revascularization if they have a non-healing ulcer

7. Intervention and Outcomes:
Bed Mobility
Reduce pressure sores
Poor blood flow can cause pressure ulcers
Transfer Training
Gait Training
Therapeutic Exercises/ Activities
Reaching out BOS support improve balance
Marching in place increase strength of muscle, which in turn help blood flow, and maintain knee ROM post-surgery
Patient Goals
Functioning Independently
Outcome
Not certain of patient full progression
Not discharged while present at hospital
Last day I saw patient
Preparing for catheterization laboratory due to calcification in lower extremity

8. Impairments/ Activity Limitation/ Participation Restrictions:
Unstable Blood Pressure: Orthostatic Hypotension
ABI indicative of severe arterial disease
BLE pain from pressure sores
Right heel more painful
Activity Limitations
Unable to go from sit to stand Independently
Unable to tolerate 1 minute standing, independently min A x 2
Unable to ambulate 3 feet independently- requires min A x 2 and RW
Participation Restriction
Unable to drive and care for his wife

9. Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients: Prospective study of individuals with diabetes, foot ulcers, and severe PVD

10. Methods: Study Population
1151 patients were included
Average Age: 75
61% males
Patients with diabetes, foot ulcers and severe PVD
Followed every patient 5 years after intervention
Treated by multidisciplinary system
All lesions assessed and documented by same team
Patient represented by one lesion below the ankle
Followed every patient 5 years after intervention, monitoring
Ulceration
New Ulcers
Amputation
Death

11. Methods: Inclusion Criteria
Diabetes mellitus and foot ulcer and systolic toe pressure <45 mm Hg, a systolic ankle pressure <80 mm Hg
Non-palpable foot pulses:
Wagner grades 4-5 or pain at rest
Grade 4: forefoot gangrene
Grade 5: Full foot gangrene
All patient fulfilled Fontaine grade 4
Ischemic ulcers or gangrene
Fontaine classification is a method by which peripheral artery disease is clinically classified.  Peripheral artery disease may be asymptomatic or symptomatic and the spectrum of symptoms is classified according to the Fontaine classification. There are 4 stages.
Wagner Classification
Most commonly used classification system for Forefoot ulcer
Grade 4: forefoot gangrene, Grade 5: Full foot gangrene
Exclusion Criteria
Medical condition not allowing angiography
Extensive gangrene but not ulcer location
Major amputation performed before angiography
Subject life expectancy of patient <6 months
Signs of ulcer healing before angiography
Lack of walking capacity before occurrence of ulcer
Informed consent for angioplasty refused

12. Methods: Doppler Inclusion Criteria:
Systolic toe and ankle blood pressure was measured using Doppler techniques
High frequency sound waves used to measure amount of blood flow in arteries and veins
Doppler:
uses high frequency sound waves (ultrasound) to measure the amount of blood flow through your arteries and veins
detect abnormal flow within an artery or blood vessel. This can help to diagnose and treat a variety of conditions, including blood clots and poor circulation
reduced amount of blood flow may be due to a blockage in the artery, a blood clot inside a blood vessel, or an injury to a blood vessel
DVT, a condition that occurs when a blood clot forms in a vein deep inside your body (usually in the leg or hip regions)
superficial thrombophlebitis, an inflammation of the veins due to a blood clot in a vein just below the skin's surface
arteriosclerosis, a narrowing and hardening of the arteries that supply blood to the legs and feet
show how much blood is currently flowing through your arteries and veins.

13. Vascular Interventions:
Angiography
Angiography vs no angiography
Angiography: X-ray of blood or lymph vessels, after introduction of radiopaque substance
No Vascular Intervention after angiography
Medical treatment provided
Percutaneous Transluminal Angioplasty (PTA)
Open up a blocked blood vessel, w/ small flexible plastic tube or catheter with balloon at end of it
Reconstructive Vascular Surgery
PTA
(Angiography)
(PTA)
Patients with no angiography: lack of mobility and presence of extensive comorbidity
No vascular intervention: intervention not feasible-continued treatment with foot care team

14. Results: Vascular Intervention and Outcome
Outcome in relation to Intervention
PTA
n=314
Vascular Surgery
n=190 n %
Primary healing
n=415
121 39 71 37
Minor Amputation
n=184 60 19 45 24
Major Amputation
n=143 34 11 31 16
Deceased
n=310 63 20 35 18
Dropouts
n=60 21 7 4 2
Still under treatment
n=34 15
Patients that survived study:
72% healed without major amputation
End of study:
Drop out rate of 5%
3% of patients were still in treatment (unhealed)

15. Results: Factors related to ulcer primary healing:
PTA and Vascular surgery increased the probability for primary healing without amputation with an odds ratio of 1.77 and 2.5 respectively
OR (95% CI)
P value
Age < 75 years
1.03 ( )
<.001
Serum Creatine <130 umol/L
1.59 ( )
.005
Ankle pressure > 50 mm Hg
1.62 ( )
.003
No congestive heart failure
1.81 ( )
.01
Single ulcer vs multiple ulcers
2.75 ( )
PTA
1.77 ( )
.02
Reconstructive Vascular Surgery
2.05 ( )
.001
Ulcer or Wagner grades I-II
2.86 ( )
Odds Ratio Definition:
The odds ratio is one of a range of statistics used to assess the risk of a particular outcome (or disease) if a certain factor (or exposure) is present. The odds ratio is a relative measure of risk, telling us how much more likely it is that someone who is exposed to the factor under study will develop the outcome as compared to someone who is not exposed.

16. Conclusion:
Factors that negatively affected the probability of healing.
Comorbidity: congestive heart failure and/or renal disease
Severity of PVD: ankle brachial index < 50 mm Hg
Extent of tissue involvement: Wagner grades 3-5 and multiple ulcers
PTA and reconstructive vascular surgery increased probability of healing without amputation
Higher primary healing rate was seen in those who had vascular intervention

17. Limitation of Study:
Unable to compare outcome of PTA or reconstructive surgery
Vascular surgery performed in patients not feasible for PTA
Negative Selection Bias
Patients admitted to university-based foot center
Possibility ulcers treated in primary health care without knowledge of foot team

18. Application to Patient:
Median Age in Study: 75
Patient: 81 years old
Increased likelihood of having PTA or vascular reconstructive surgery due to:
ABI indicative: Severe arterial disease
If patient has a procedure such as PTA or vascular reconstructive surgery
Prognosis: Odds ratio of primary healing, good

19. Early Revascularization after Admittance to Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes

20. Methods: Study Population
478 patients prospectively included
Diabetes, foot ulcers, and severe PAD
Average age: 74 yo
Male: 60%
Treated and followed by a multidisciplinary foot team
Continuous follow up until healing or death

21. Methods: Inclusion Criteria
Patients with diabetes mellitus, foot ulcer and a systolic toe pressure <45 mm Hg and or systolic ankle pressure < 80 mm Hg (Doppler techniques)
Non-palpable foot pulses with an ulcer Wagner grade 4-5 or pain at rest
Rest pain: Severe persistent pain localized to foot and relieved by dependency
All patients were Fontaine grade 4
Exclusion Criteria
Patients who did not have invasive revascularization
Say it is the same a prior study

22. Methods: Study Design
Either had percutaneous transluminal angioplasty (PTA) or reconstructive surgery
PTA not feasible, surgery next option
Time to revascularization calculated
First visit to diabetic foot center
All lesions assessed and documented by same team

23. Results: Probability of ulcer healing without major amputation
Relation to maximal tissue destruction reached during follow-up
Relation to time to revascularization
Shorter time to revascularization, Wagner grade <3

24. Factors affecting the probability of healing over time
Results:
Time to revascularization
Factors affecting the probability of healing over time
No difference between patients who had PTA or reconstructive surgery regarding ulcer progression
Median Healing time
10 months
HR (95% CI) P
Intermittent Claudication
1.64 ( )
<0.001
Peripheral edema
0.76 ( )
0.033
Max. Wagner grades < 3 reached
1.92 ( )
Time to intervention < 8 weeks
1.96 ( )
Shorter time to revascularization, Wagner grade <3 and presence of intermittent claudication were significantly related to higher probability of healing without major amputation over time
Presence of peripheral edema significantly related to lower probability of healing
Median healing time primary healing
8 months
Median healing time after minor amputation
14 months

25. Conclusion:
Factors affecting probability of healing without major amputation
Shorter time to revascularization
Extent of tissue destruction
Peripheral edema
Intermittent claudication
80% of surviving patients healed without major amputation

26. Limitations to Study:
Decision for vascular intervention at the discretion of vascular surgeon
No control group
Either received PTA or reconstructive vascular surgery
Time to revascularization calculated from first visit with foot team
Foot ulcer onset is usually unknown

27. Application to patient:
Average Age 74 yo
Patient: 81 yo
After catheterization lab results?
Depending on degree of calcification may determine whether patient needs PTA or reconstructive vascular surgery
Median healing time 10 months
Prognosis: Fair due to length of healing time
Patient does have son that is available 24/7
Patient motivated

28. Conclusion: Shorter time to revascularization
Is peripheral vascular disease/ peripheral artery disease a valid prognostic factor for determining the healing process of foot pressure ulcers in an 80 year old man?
Why is this important to PT?
As clinicians able to perform ABI
Analyze results
Make physician aware of results
Severe arterial disease
Effects progress of pressure ulcer healing
May deter patient from ambulation, due to pain
Perform exercise that avoid pressure on ulcer
Clinical Question?
PAD and PVD negative impact on healing process of foot ulcer
Healing time potentially 10 months
motivation of patient?
Once patient has surgery the importance of mobility to increase blood flow
Shorter time to revascularization
Extent of tissue destruction
Peripheral edema
Intermittent claudication
Comorbidity: congestive heart failure and/or renal disease
Severity of PVD: ankle brachial index < 50 mm Hg
Extent of tissue involvement: Wagner grades 3-5 and multiple ulcers

29. Resources:
Apelqvist, J., Elgzyri, T., Larsson, J., Londahl, M., Nyberg, P., Thorne, J. (2011). Factors related to outcome of neuroischmeic/ischemic foot ulcer in diabetic patients. Journal of Vascular Surgery, 53(9), Retrieved from
Apelqvist, J., Elgzyri, T., Eriksson, K., Larsson, J., Nyberg, P., Thorne, J. (2014). Early Revascularization after Admittance to a Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes. European Journal of Vascular and Endovascular Surgery, 48 (7), Retrieved from
Images
detect-vascular-disease/
(Angiography)
(PTA)

30. Questions?