Management of Pad in Primary Care Podiatry

MANAGEMENT OF PAD IN PRIMARY CARE PODIATRY

“ MY NAME IS FESTER……. IT MEANS TO ROT” FOR THE FIRST TIME IN HISTORY

NON-COMMUNICABLE DISEASES ARE THE MAJOR CAUSE OF MORTALITY IN THE WORLD

AGING EFFECTS

DIABETES RELATED

PAD

OBESITY EFFECTS PAD AND AGING PAD

•COMMON •MAJORITY ARE ASYMPTOMATIC •ATYPICAL LEG SYMPTOMS ARE COMMON •CLASSIC CLAUDICATION IN 10-35% •DETECTION ELUSIVE UNLESS SOUGHT QUESTION..

• YOU QUALIFY PATIENT FOR PREVENTIVE CARE BASED ON PAD ASSOCIATED FINDINGS • WHAT ARE YOU DOING ABOUT THE PAD ? • REFER ? • TREAT ? • IGNORE ? • WHAT HAPPENS IF AND WHEN THE PATIENT “CRASHES” • WHERE WERE YOU DOCTOR ?

PAD ASSOCIATED PATHOLOGY

•5X INCREASED RISK OF CARDIOVASCULAR MORTALITY •3X INCREASED RISK ALL-CAUSE MORTALITY OVERLAP OF PAD SURVIVAL OF PAD PATIENTS EVENT-FREE SURVIVAL WITH PAD DIABETES ULCERS IN THE DIABETIC PATIENT

NEUROPATHIC NEUROISCHEMIC ISCHEMIC

AMPUTATIONS IN THE DIABETIC PATIENT

•DELAYED PRESENTATION OF PATIENT FOR CARE •DELAYED DIAGNOSIS •DELAYED TREATMENT •INADEQUATE TREATMENT •FAILURE TO RECOGNIZE PAD PAD IN THE OLDER PATIENT

• ONLY 40-50% WITH PAD ARE SYMPTOMATIC • SIGNS ARE MORE IMPORTANT THAN SYMPTOMS • INCREASING LIABILITY FOR “FAILURE TO DIAGNOSE OR REFER” SYMPTOM-BASED CLASSIFICATION OF PAD “CRITICAL LIMB ISCHEMIA”

ANKLE PRESSURE < 40MMHG WITH REST PAIN ANKLE PRESSURE < 60MMHG WITH GANGRENE

TOE PRESSURES < 40MMHG

TcO2<30 MMHG

PRESENCE OF TISSUE NECROSIS

DIABETIC PATIENT NOT INCLUDED

WHAT ABOUT THE DIABETIC •ULCERATION PATIENT ? •INFECTION DOES CRITICAL LIMB ISCHEMIA ALONE DEFINE THE NEED FOR AMPUTATION ?

MARSTON STUDY CIRCULASE TRIAL ELGZYRI STUDY

• 13% AMPUTATION • 19% AMPUTATION • 50% HEALING WITH RATE AT 6 MONTHS RATE AT 6 MONTHS WOUND CARE OR • MOST OFTEN DUE • 23% AMPUTATION MINOR AMPUTATION TO INFECTION RATE AT 12 MONTHS • 17% MAJOR • 52% WOUND AMPUTATION HEALING AT 12 • 33% DIED WITH MONTHS WITHOUT UNHEALED WOUNDS REVASCULARIZATION

PAD IN THE OLDER PATIENT

• MAY NOT WALK FAR ENOUGH • MAY NOT WALK FAST ENOUGH • MAY NOT WALK AT ALL • MAY HAVE ATYPICAL SYMPTOMS • MAY HAVE SUFFICIENT COLLATERAL CIRCULATION • MAY NOT DISCUSS WITH PODIATRIC PHYSICIAN • GENERALLY, WOMEN HAVE MORE SYMPTOMS THAN MEN INITIAL EVALUATION

•HISTORY •LOW TECHNOLOGY, HIGH TOUCH EXAMINATION •ABI, DOPPLER EXAMINATION •PATIENT EDUCATION •TREATMENT OF PAD •TREATMENT OF ASSOCIATED RISK FACTORS •REFERRAL WHEN INDICATED VASCULAR EVALUATION/ABI/DOPPLERS

•LEG OR FOOT SYMPTOMS OR SIGNS •NON-HEALING WOUNDS •AGE > 65 •AGE > 50 • WITH DIABETES • WITH HISTORY OF SMOKING • WITH PAD RISK FACTORS • DISORDERS WITH WHICH PAD IS ASSOCIATED

CIRCULATION, NOV, 2011 CLAUDICATION: WHAT HAPPENS ? ASYMPTOMATIC PAD

• 20% OF HIGHER >70 YEARS • INCREASED RISK FOR MORTALITY AND CV EVENTS • EXERCISE, LIFE-STYLE MODIFICATIONS • SMOKING CESSATION • WEIGHT LOSS • RISK FACTOR MODIFICATIONS • HYPERTENSION • TREATMENT OF LOWER EXTREMITY RISK FACTORS • SKIN DISORDERS • DEFORMITIES CLASSIC THERAPY

•ANTI-PLATELET THERAPY •LIPID-LOWERING THERAPY • LDL < 100 MG/DL • LDL < 70 MG/DL IN HIGH RISK PATIENT •ANTI-HYPERTENSIVE THERAPY • < 140 MM/HG • < 130 MM/HG IN DM, CKD CLAUDICATION: PODIATRIC INTERVENTIONS

•EXERCISE THERAPY •LIFE-STYLE MODIFICATIONS •PHYSICAL THERAPY •PHARMACOLOGIC THERAPY EXERCISE FOR CLAUDICATION: SVS EXERCISE THERAPY FOR CLAUDICATION

•3-5 SUPERVISED SESSIONS PER WEEK •35-60 MINUTES PER SESSION •TREADMILL OR TRACK WALKING TO NEAR CLAUDICATION DISTANCE •6 MONTHS •100-150% IMPROVED WALKING DISTANCE •IMPROVED QUALTY OF LIFE EXERCISE FOR CLAUDICATION ARTERIAL ASSIST PUMPS PRESCRIPTION THERAPY

•SEQUENTIAL FOOT AND CALF COMPRESSION •120 MM/HG •INFLATION, DEFLATION UNDER 0.5 SEC •I HOUR DAILY •INCREASES NITRIC OXIDE •STIMULATES ANGIOGENESIS MEDICATIONS/SUPPLEMENTS SVS RECOMMENDATIONS

• SMOKING CESSATION • STATIN THERAPY • OPTOMIZING DIABETES CONTROL • ASPIRIN 75-325 MG • CLOPIDROGEL 75 MG DAILY • CILOSTAZOL 100 MG BID • IF NO CHF OR CONTRA-INDICATION • PENTOXIFYLLINE 400 MG TID • ACEI RAMIPRIL 10 MG DAILY CLAUDICATION: TREATMENT L-CARNITINE (2-4 GMS/DAY) GINKO BILOBA (120-180 MG/DAY) ARGENINE (3 GMS/3X DAY) VITAMIN E CLAUDICATION TREATMENT ASPIRIN FOR PAD ? ASPIRIN ASPIRIN PAD CLAUDICATION

•PENTOXIFYLLINE •TRENTAL, ARTAL, PENTILIN, PENTOXIN •400mg TID •CILOSTAZOL •PLETAL •100 mg BID CILOSTAZOL

HYPERHOMOCYSTEINEMIA

•ELEVATED HCY ASSOCIATED WITH VASCULAR DISEASE •LMF, B12 SUPPLEMENTATION MAY REVERSE DEFICIT •ACCENTUATED IN THE DIABETIC PATIENT •MORE COMMON WITH METFORMIN UTILIZATION HOMOCYSTEINE METABOLISM

REMETHYLATION METHIONINE TRANSSULFURATION

THF S-ADENOSYL METHIONINE

FOLATE CYCLE BETAINE BHMT B12 S-ADENOSYL METHYLENE-THF DIMETHYLGLYCINE HOMOCYSTEINE METHIONINE SYNTHASE

MTHFR

HOMOCYSTEINE CYSTEINE METHYL-THF B6, CYSTATHIONINE β SYNTHASE NITRIC OXIDE VASODILATION

ENDOTHELIAL NO VASODILATION L-METHYL FOLATE

arginine

BH4 INCREASED VASCULARITY

De LUIS D; FERNANDEZ N; ALLER R; MED CLIN (BARC) 122 (1) 2004 REVASCULARIZATION FOR CLAUDICATION ? REVASCULARIZATION FOR CLAUDICATION ?

BYPASS VS. ENDOVASCULAR: QUESTIONS

•IS THERE A TARGET VESSEL ? •IS THERE A CONDUIT ? •WHAT IS THE HEALTH STATUS OF THE PATIENT ? •DURABILITY ? RACIAL AND GENDER DISPARITIES 50

6 MONTH OUTCOME 45 FOR DRUG ELUTING 40 STENTS/ANGIOPLASTY FOR LEG ISCHEMIA 35

0 ULCER IMPROVED, MINOR AMPUTATION, MAJOR AMPUTATION Category 4 HEALED FURTHER INTERVENTION BKA WHAT IS “SUCCESS” ?

PROPER SCREENING OF COST IS JUSTIFIED IF A SUPPORT FOR OPTIMAL PATIENTS IS CRITICAL HEALING OF THE RESOLUTION OF MAJOR AMPUTATION IS BIOMECHANICAL WOUND ISCHEMIA •IDENTIFICATION OF AVOIDED RECONSTRUCTION PROVOCATIVE NON-VASCULAR RISK FACTORS RESOLUTION OF WOUND HYPOXIA

• SURGICAL REVASCULARIZATION • ANGIOPLASTY +/- STENTS • DEBRIDEMENT NECROTIC TISSUE • AMPUTATION TO LEVEL OF ADEQUATE CIRCULATION • HYPERBARIC OXYGEN • SYSTEMIC • TOPICAL MONITOR FOR RE-STENOSIS TYPICAL POST- PROCEDURE HISTORY MONITOR FOR COMPLICATIONS RESTENOSIS IS THE ACHILLES HEEL OF LOWER EXTREMITY ENDOVASCULAR INTERVENTIONS

•SURVEILLANCE 1, 6, 12 MONTHS •CHANGING RUTHERFORD CLASSIFICATION •ALTERATION IN WOUND HEALING PROGRESS •NEW SIGNS/SYMPTOMS SUMMARY •FOLLOW GUIDELINES FOR VASCULAR TESTING •REFER WHEN APPROPRIATE •EDUCATE PATIENT AND FAMILY REGARDING RISKS •ANNUAL REEVALUATION •OFFICE BASED MANAGEMENT THE ARTERIAL- VENOUS ULCERATION: NEITHER FISH NOR FOWL THE PROBLEM OF ULCERATION

• UP TO 5% POPULATION OVER 65 YEARS OF AGE • DIRECT COST $3 BILLION • 45%-90% ARE VENOUS ULCERATION • MIXED ARTERIAL-VENOUS ULCERATION UP TO 26% CHRONIC VENOUS INSUFFICIENCY

MOST NEURO-ISCHEMIC DIABETIC COMMON FOOT ULCERATION LOWER NON-ISCHEMIC DIABETIC EXTREMITY NEUROPATHY ULCERATIONS ARTERIAL INSUFFICIENCY CLASSIC EDUCATION

• VENOUS • DECUBITUS/PRESSURE • ARTERIAL • NEUROPATHIC • HYPERTENSIVE • CT DISEASE • HEMOGLOBINOPATHIES • MALIGNANCY

CLASSIC TEACHING: ITS EITHER FISH OR FOWL VENOUS ULCERATION ARTERIAL-VENOUS ULCERATION EPIDEMIOLOGY OF MIXED ARTERIAL-VENOUS ULCERATION

• ARTERIAL INSUFFICIENCY WITH VLU’S 15%-30% • MODERATE • ABI 0.5-0.9 • TOE PRESSURE 50-90 MM/HG • SEVERE • ANKLE PRESSURE < 70MMHG • TOE PRESSURE < 50MMHG PATHOPHYSIOLOGY

• VENOUS DISEASE • VENOUS REFLUX MIXED ARTERIAL-VENOUS • VENOUS OBSTRUCTION ABSENT PEDAL PULSES • ARTERIAL DISEASE INFLOW ARTERIAL STENOSIS > 50% ABI < .90 • INADEQUATE PERFUSION SUPERFICIAL AND DEEP VENOUS INSUFFICIENCY • INADEQUATE OXYGENATION DVT ON DUPLEX US ARTERIAL-VENOUS ULCERATION: EFFECTS OF ARTERIAL INSUFFICIENCY

•LOWER VENOUS ULCER HEALING RATES •AVERAGE CLOSURE TIME 4 MONTHS •85% WOUNDS HEALED AT 12 MONTHS

TREATMENT OF VENOUS HYPERTENSION

•COMPRESSION THERAPY •ENDOVENOUS ABLATION •VENOUS STENTING ULCERATION LIKELY VENOUS ARTERIAL REVASCULARIZATION

EVALUATE CONSIDER CONSIDER

EVALUATE NON- CONSIDER CONSIDER INVASIVE VASCULAR ANGIOGRAPHY ENDOVASCULAR US ARTERIAL TREATMENT OR STUDIES BYPASS

DANGERS OF COMPRESSION THERAPY ARTERIAL –VENOUS ULCERATION INJURY FROM COMPRESSION EDEMA RISK: COMPRESSION THERAPY INJURY

VENOUS COMPRESSION THERAPY GENERAL APPROACH

HISTORY AND PHYSICAL EXAMINATION NON-INVASIVE VASCULAR US STUDIES FOR VENOUS DISEASE NON-INVASIVE VASCULAR US STUDIES FOR ARTERIAL DISEASE IDENTIFY CONFOUNDING FACTORS FOR WOUND HEALING OPTIMIZE NUTRITION DEBRIDEMENT

OPTIMAL TREATMENT ALGORITHM UNCLEAR

TREATMENT CORRECT CAUSE(S) OF OF ARTERIAL- ULCERATION VENOUS ACHIEVE WOUND HEALING ULCERATION PREVENT RECURANCE OF ULCERATION REDUCE THE STRENGTH OF COMPRESSION

PROTECT VULNERABLE AREAS

TREATMENT • Malleoli OF MIXED • Heel • Anterior tibia ARTERIAL- • Over tendons VENOUS AVOID HIGH COMPRESSION THERAPY WITH ULCERATION ANKLE PRESSURE <80MMHG

ARTERIAL REVASCULARIZATION

• Ankle pressure < 60mmhg • Abi < 50mmhg REVASCULARIZATION WITH ARTERIAL-VENOUS ULCERS

•59 PATIENT’s WITH MAV ULCERS •58% HEALING AT 7.9 MONTHS •7 PATIENTS WITH BKA •8 FAILED REVASCULARIZATIONS •HISTORY OF DVT POOR PROGNOSTIC INDICATOR (15% HEALING)

Treiman GS, Copland S, McNamara RM, Yellin AE, Schneider PA, Treiman RL. Factors influencing ulcer healing in patients with combined arterial and venous insufficiency. J Vasc Surg. 2001;33:1158–1164 PERCUTANEOUS REVASCULARIZATION

•27 PATIENTS WITH MAV ULCERS •ENDOVASCULAR INTERVENTION+ COMPRESSION •AVERAGE ABI INCREASE 0.56 TO 0.97 •75% HEALING AT 10 WEEKS

Lantis JC II, Boone D, Lee L, Mendes D, Benvenisty A, Todd G. The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease. Ann Vasc Surg. 2011;25:79–86 VENOUS TREATMENT

•EVALUATE FOR SUPERFICIAL VALVULAR DISEASE •CONSIDER ENDOVENOUS ABLATION FOR SAPHENOUS VEIN REFLUX •CONSIDER SCLEROTHERAPY OR ENDOVASCULAR ABLATION OF PERForATOR VEINS PRIMARY ARTERIAL ULCERATION WITH ASSOCIATED CHRONIC VENOUS INSUFFICIENCY

• EDEMA PROBLEMATIC FOLLOWING SURGERY • 3%-12% WOUND BREAKDOWNS • 27% WOUND INFECTION • INTERVENTIONS TO CONSIDER • CONSTANT ELEVATION • INTERMITTENT PNEUMATIC COMPRESSION • LIMB BANDAGING • COMPRESSION PRIMARY ARTERIAL ULCERS WITH ASSOCIATED CHRONIC VENOUS INSUFFICIENCY • POST REVASCULARIZATION EDEMA • DEEP-TUNNELED GRAFTS • IPC FOOT AND CALF • SUPERFICIAL TUNNELED GRAFTS • NO COmPRESSION X3 DAYS • IPC DISTAL TO GRAFT ENDPOINT • POST OPERATIVE COMPRESSION • Toes to knee 20mmhg-30mmhg WOUND CARE

•APPROPRIATE TOPICAL THERAPY •DEBRIDEMENT AS NECESSARY •APPROPRIATE DRESSINGS CONSIDERATIONS

• PENTOXIFYLLINE • L-METHYL FOLATE, P5P, METHYLCOBALAMIN • TOPICAL LIDOCAINE, BUPIVACAINE • TOPICAL CA-CHANNEL BLOCKERS (EG: VERAPAMIL, NIFEDAPINE)