Keys To Diagnosing And Addressing PAD In Patients With Wounds

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Author(s): 
Kazu Suzuki, DPM, CWS

Q:

What kind of precautions do you take on following up with your patients who had recent vascular intervention or bypass surgery?

A:

The key is close monitoring, according to Dr. Bell. He often treats patients who have undergone recent bypass or cardiovascular intervention. Dr. Bell notes that he frequently sees such patients more often during the critical post-op time period than the surgeon or interventionalists who performed the procedure.

    “We become the other set of eyes. If symptoms of ischemia return or if a complication is observed, we make immediate contact with that specialist,” says Dr. Bell.
Dr. Bell emphasizes the importance of patient education. Reminding patients not to ignore symptoms or encouraging them to speak up “when something just doesn’t seen right” helps reduce post-procedure complications.

   Dr. Suzuki first ensures that patients are following up with their appointments with vascular specialists. Although it can be easy for patients to forget appointments, he emphasizes the importance of routinely scheduled “surveillance” of the bypass graft or stented arteries with arterial Doppler machines to ensure adequate blood flow and detect restenosis as early as possible.

   Dr. Suzuki also notes that re-opened blood vessels or bypass grafts may close down over time. He emphasizes vigilant monitoring for the signs and symptoms of leg ischemia by asking about the patient’s pain level and ability to walk, and checking the wound and skin status.

   Dr. Bevilacqua supports “aggressive management” of lower extremity wounds in patients after bypass surgery. He adds that one must debride wounds of all non-viable tissue and prefers an aggressive approach to closure.

   Dr. Suzuki says the conventional thinking is that surgeons should not use a tourniquet during foot and ankle surgeries (such as toe or foot amputations) after revascularization procedures. He notes that the tourniquet, especially with prolonged use, may facilitate new occlusions in the leg arteries or possibly disrupt the bypass conduit, especially if the leg bypass procedure was recent.

    “Some of my colleagues disagree with me on this point but I take a ‘better to be safe than sorry’ approach with this particular topic,” says Dr. Suzuki.

   Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.

   Dr. Bevilacqua is a foot and ankle surgeon at North Jersey Orthopaedic Specialists in Teaneck, NJ. He is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.

References
1. Olin JW, Allie DE, Belkin M, et al. 2010 Performance measures for adults with peripheral arterial disease. J Am Coll Cardiol. 2010; 56(25):2147-2181.
2. Khan NA, Rahim SA, Anand SS, et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006; 295(5):536-546.
3. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA guidelines for the management of patients with peripheral arterial disease. J Am Coll. Cardiol. 2006; 47(6):239-312.

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