Key Insights On Working With Vascular Specialists To Manage PAD

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Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

   When making a referral, Dr. Bevilacqua emphasizes the importance of including the patient’s pertinent medical, surgical and social history. He also notes the patient’s previous treatments and wound progression. Dr. Bevilacqua notes that wounds will not predictably heal in the presence of CLI and restoration of pulsatile blood flow to the foot should be the goal.

    “A seemingly simple foot ulcer is often the manifestation of a much larger problem,” notes Dr. Bevilacqua.

   Dr. Suzuki will advise that the specialists be aggressive and provide “as much blood flow as they can re-establish and as close as they can go to the target site” to optimize wound healing. In regard to the specific procedure (such as a leg bypass, angioplasty or atherectomy), Dr. Suzuki says vascular specialists often decide on the given procedure(s) based on experience, the patient’s overall medical status and disease anatomy (such as the presence or absence of a bypass target). Having said that, he notes that in his experience, large lower extremity ischemic wounds benefit from a leg bypass that may supply a large, pulsatile amount of blood flow to the targeted area.

Q:

How do you manage the gangrenous toe wounds until you can get the patients to see a vascular specialist?

A:

In the event that the referral takes more than a day or two, Dr. Bell emphasizes that the podiatrist’s role is to focus on pain management and infection control. Acknowledging that this is a case-by-case issue, he may sometimes order patients to apply topical nitroglycerin daily to the affected foot to assist in perfusion to the extremity and gangrenous digit. Generally, he keeps the gangrenous digit protected and will often order a non-stick antibacterial dry dressing, such as xeroform gauze, to the affected digit. Dr. Bell will not do anything aggressive until the patient has optimal reperfusion.

   For dry, gangrenous wounds, Dr. Suzuki uses a povidone-iodine (Betadine, Purdue Pharma) solution or swab-stick to paint the wounds, which he subsequently covers with sterile, dry gauze dressings. Dr. Suzuki feels the alcohol in Betadine keeps the wound dry while keeping the bacteria count low. He says this may prevent skin infection.

   If a digital wound or dry gangrene is present and there are no clinical signs and symptoms of infection, Dr. Bevilacqua advises delaying definitive debridement until a revascularization procedure can restore blood flow. He says one must closely monitor the wounds for any signs of infection that may necessitate emergency debridement.

Q:

How do you manage the gangrenous toe wounds after the blood flow is re-established?

A:

After blood flow has been re-established, Dr. Suzuki treats gangrenous wounds aggressively as “necrotic, open wounds.” As soon as possible, he will attempt to treat the wounds surgically by amputating the gangrenous tissue, leaving healthy margins. After blood flow has been restored, Dr. Bevilacqua says one may perform definitive debridement to remove all non-viable tissue.

   After perfusion has been re-established to a gangrenous toe and ischemic lower extremity, Dr. Bell will manage the wound care, whether the toe requires amputation or is salvageable. He will communicate with the cardiovascular interventionalist on the patient’s progress.

    “Just as (vascular specialists) provide the expertise in the revascularization, we provide the expertise in wound management,” notes Dr. Bell. “We practice the team approach to limb salvage through communication and mutual respect, and always with the patient’s best interests being our primary motivation.”

   The non-surgical option is an autoamputation, says Dr. Suzuki. In this situation, one “leaves alone” the gangrenous toes, which fall off on their own over several months to a few years.

    “I do not believe in this treatment option except for the most ill patients who are considered terminal or in hospice,” says Dr. Suzuki. “In real practice, this auto-amputation treatment rarely works and the patient usually becomes infected or septic before the demarcation happens.”

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