When treating patients with peripheral arterial disease (PAD), it is vital to ensure proper referrals to trusted vascular specialists. These expert panelists discuss what information to include in referrals and how to manage wounds until patients can see vascular specialists.
Once you diagnose PAD, what is your referral method to other medical doctors and vascular specialists?
Early recognition of PAD and prompt referral to a vascular specialist are essential, according to Nicholas Bevilacqua, DPM. As he notes, a comprehensive, multidisciplinary approach improves the quality of care. Dr. Bevilacqua says the collaboration between the vascular surgeon and the podiatrist is a natural partnership that complements the skills of each specialist. He has daily interaction with vascular surgeons and will call them directly while the patient is in the office in order to arrange follow-up consultation. Dr. Bevilacqua does not rely on patients to schedule their own appointments, emphasizing that any delay in care can compromise the outcome.
For Kazu Suzuki, DPM, CWS, the referral method depends on the degree of PAD and the treatment plan for the particular patient. If the degree of ischemia is mild, he may check with the patient’s doctor (internist, diabetologist and/or cardiologist) to make sure the blood pressure, cholesterol and blood glucose are optimized as per the American College of Cardiology/American Heart Association PAD management guideline.1 Dr. Suzuki may suggest a consultation with a nutritionist and encourage daily walking exercise.
On the other hand, if Dr. Suzuki suspects moderate or severe PAD in the form of critical limb ischemia (CLI), he would notify the patient’s medical doctor right away. He would also make an immediate referral to a vascular specialist (vascular surgeon, interventional radiologist, interventional cardiologist) in his hospital.
Desmond Bell, DPM, notes his practice is unique as he only treats patients with chronic, non-healing wounds. He says many already have been diagnosed with PAD. His practice can make a difference when he discovers a suspected underlying occlusion or overall worsening of the PAD that exacerbates the condition of the wound.
“We have developed strong relationships with several cardiovascular interventionalists in the Jacksonville region. We make immediate referrals to them, whether they are cardiologists or vascular surgeons,” notes Dr. Bell. “We often keep the vascular interventionalists informed of their patient’s condition between their follow-up appointments.”
As you make your referral, what kind of information do you relate to the vascular specialist?
Dr. Suzuki gives as much information as he can to the vascular specialist. He will send the skin perfusion pressure/pulse volume recording (SPP/ PVR) test results, size of the wounds, digital photos and when he expects that the specialist should see the patient. Likewise, Dr. Bevilacqua says one should include the results of non-invasive vascular studies, noting that these studies provide valuable information and may help determine the need for further workup or intervention.
At the time of referral, Dr. Bell discusses with the specialist his recent findings or suspicions of worsening of the patient’s PAD that may be leading to CLI. He notes this often revolves around several factors, including increasing pain and clinical deterioration of any wounds, cursory Doppler results and a comparison to available baseline findings.
“The overall clinical picture with these specifics is usually enough to warrant a recommendation for an expedited or stat appointment for the patient with the cardiovascular interventionalist,” says Dr. Bell.
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.
How do you manage the gangrenous toe wounds until you can get the patients to see a vascular specialist?
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.
How do you manage the gangrenous toe wounds after the blood flow is re-established?
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.”
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 an Associate in Foot and Ankle Surgery at North Jersey Orthopaedic Specialists in Teaneck, N.J. 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.
1. 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.