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

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 Infection Neuropathy

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. 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 (TCPO 2 ) 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. 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

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”