Current Concepts In Treating Ischemic Foot Ulcers
A: Dr. Brenner calls ABIs of less than 0.6, along with rest pain and/or lesions, discoloration or claudication, “a red flag” for immediate referral to an appropriate PVD specialist. Following ABI and duplex scanning, a vascular surgeon would usually undertake MRA, CTA and a DS angiogram, according to Dr. Brenner. After performing these diagnostic tests, he says the vascular surgeon would usually perform interventional endovascular procedures as an alternative to bypass or possibly in conjunction with it.
Dr. Zarrinmakan considers an arteriogram when a patient requires revascularization. In patients with renal insufficiency, allergies to iodinated contrast and severe multilevel disease, he says MRA and ultrasound are excellent choices for imaging.
Dr. Allie “very rarely” uses MRA, even though he says it has merit in CLI patients with renal insufficiency. According to Dr. Allie, MRA is time consuming and limited in patients with stents, clips and pacemakers. Alternatively, one may can obtain new noninvasive, intravenous, 3-D, multichannel CTA in the outpatient office setting with scan times of less than 30 seconds, points out Dr. Allie. He says CTA has no metallic limitations and is more accurate today than single planar traditional hospital-based angiography without the risks of an “arterial stick,” such as bleeding, vessel thrombosis, hematoma or infection.
“I must emphasize that CTA is noninvasive. In 2007, no patient should undergo a primary amputation without at least a vascular surgical or interventionalist consult, vascular CTA and/or angiography,” adds Dr. Allie.
Dr. Allie notes the risks of CTA or angiography today are far lower than a below-knee amputation (BKA) or above the knee amputation (AKA), which have a 30-day preoperative morbidity/mortality rate of 10 to 40 percent. He emphasizes that the benefits of revascularization include more than 90 percent limb salvage rates with minimal risks such as morbidity/mortality rates of less than 5 percent. He says an aggressive approach towards angiography and revascularization is important.
In an 18-month study of a U.S. Medicare database of 417 CLI patients, Dr. Allie notes that he and his co-authors found that over 60 percent of the patients had a primary amputation as their first treatment. Additionally, the study found that less than 30 percent received a vascular or interventional surgical consult, and only 38 percent had an ABI and 16 percent had angiography.2
Q: What wound products do you utilize in ischemic foot wounds?
A: For Dr. Zarrinmakan, treatment of ulcers encompasses the broad categories of revascularization, antibiotics, topical wound care therapies and compression garments.
Dr. Brenner uses topical activated collagen preceded by Ocean Aid spray or foam (Ocean Aid). After taking appropriate cultures, if indicated, he starts with a systemic antibiotic such as amoxicillin/clavulanic acid (Augmentin, GlaxoSmithKline) or levofloxacin (Levaquin, Ortho-McNeil). He will switch these when culture reports indicate another sensitivity.
With over 25 years of experience in vascular surgery, Dr. Allie has used the whole gamut of wound care products and works closely with podiatrists. He advocates early revascularization followed by local wound sepsis-antisepsis control and aggressive early wound coverage with minimal debridement.
For all open wounds, Dr. Allie uses Dermacyn (Oculus Innovative Sciences) to achieve immediate local wound sterilization. Dermacyn, a recently approved superoxidized antiseptic solution, has been shown to achieve “exceedingly high” cidal levels against all bacteria, viruses and spores, including methicillin-resistant Staphylococcus aureus (MRSA), as reported in a recent randomized trial.3
“In my hands, Dermacyn has replaced all topical agents and solutions for ischemic foot wounds, and decreased the need for oral or intravenous antibiotics, hospitalizations and debridement,” notes Dr. Allie.