Keys To Diagnosing And Addressing PAD In Patients With Wounds
What kind of PAD workup do you do in your practice?
From the patient interview and history, Dr. Suzuki can make an “educated guess” on the probability of PAD. Dr. Bevilacqua questions patients about common symptoms associated with PAD (claudication and/or rest pain).
As for the physical exam, Drs. Bevilacqua and Suzuki palpate femoral, popliteal and pedal pulses. If Dr. Suzuki cannot palpate the pulses, he may use a handheld Doppler or utilize the skin perfusion pressure/pulse volume recording (SPP/PVR) test to determine the degree of leg ischemia. Dr. Bevilacqua assesses the ankle brachial index (ABI) in all patients with diabetes over the age of 50 or younger patients with multiple PAD risk factors.
Since Dr. Bell’s practice specializes in treating patients with wounds and PAD, he says the issue is more in determining the degree of PAD. He does palpate pedal pulses but considers this test “very unreliable” when attempting to quantify the degree of PAD even when one can appreciate pulses. Using a simple Doppler allows Dr. Bell to hear the quality of blood flow and he notes the presence of turbulence is always a concern.
Dr. Bell will refer the patient to a vascular specialist if he discovers trophic changes such as rubor, cyanosis, decreased hair growth and delayed capillary refill along with other risk factors for significant PAD. He also works closely with interventional cardiologists.
What kind of non-invasive tests for PAD do you do in your practice?
Dr. Suzuki mainly uses a SPP laser Doppler (SensiLase, Vasamed), which can measure both SPP and PVR. He has found the combination of SPP/PVR is adequate enough to make an accurate diagnosis of PAD and refers the patient appropriately based on the test results. Dr. Suzuki no longer uses transcutaneous oximetry (TcPO2) as it takes over 30 minutes and is often inaccurate in his patient demographics.
Although he acknowledges the ABI is a useful tool for screening for PAD in the general population, Dr. Suzuki often finds he cannot measure ABI due to the rigid leg arteries that occur in elderly patients and patients with diabetes. Dr. Bell also expresses concern with ABI testing. Since most of his patients have diabetes, Dr. Bell says their non-compressible arteries make the test results unreliable in a number of cases.
Although the ABI is the initial step in non-invasive evaluation, Dr. Bevilacqua says the toe brachial index (TBI) may be a better assessment of peripheral pressure. He notes the smaller vessels in the toes are generally spared from calcification. When it comes to patients presenting with an ulcer, Dr. Bevilacqua says one can assess the periwound perfusion with a laser Doppler, which may aid in predicting healing.
Dr. Bell will make a referral when he is strongly suspicious of PAD.
“Getting patients to a specialist who not only determines the extent of PAD through invasive or non-invasive testing, but can then improve blood flow and, as a result, wound healing outcomes, is more expeditious,” asserts Dr. Bell.
What kind of precautions do you take on following up with your patients who had recent vascular intervention or bypass surgery?
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.