When Do You Refer A Patient For Vascular Intervention?
Portable Doppler examination of pedal pulses can provide audible evidence of turbulence in partially to severely occluded arteries. However, one should correlate this with other exams such as segmental waveforms when screening for PAD. Again, the provider’s ability to determine the quality of audible signals suggestive of mild, moderate or severe PAD is an obvious variable. This variable makes relying on a Doppler exam for the diagnosis of PAD less than optimal despite its important place overall as a tool in the vascular disease assessment toolbox.
The point here is that in-office screening for PAD should not really be confused with the actual diagnosis of PAD. Yes, screening is very important but when one suspects PAD, it is imperative that referral to a vascular specialist occur.
Stressing The Mortality Rates Associated With PAD
I cannot emphasize enough the importance of PAD recognition and the five-year mortality rates that compare several potentially fatal conditions support this point.3-8
Simply stated, PAD carries a potential for death that is greater than both prostate and breast cancer combined. Yet providers and the public alike are seemingly unaware of the gravity associated with PAD.
Imagine the scenario in which a woman who has recently discovered a lump on her breast and what ensues upon presenting to her primary care physician. There would likely be an immediate call to action as the PCP would pursue appropriate diagnostic testing and a referral to a specialist would be the standard of care.
Yet what happens when a patient presents with either a non-healing diabetic foot ulcer or generalized pain in the legs and feet upon elevation or during ambulation? In the case of the non-healing diabetic foot ulcer, is referral to a wound specialist the standard of care or is the norm the prescribing of an oral antibiotic and orders to keep a dressing in place? How often do we consider PAD in a neuropathic patient due to the overlap of symptoms between the two conditions? In either case, a lack of urgency to refer to either a wound or vascular specialist may be rooted in the lack of understanding that this patient is actually presenting with a life-threatening condition.
A Closer Look At Classifying PAD And CLI
To better understand the course of progression that PAD may take, the Rutherford-Becker categorization can be extremely useful when considering the potential severity of the disease.
The Rutherford-Becker Classification system to categorize the extent and level of PAD suggests that Category 4 through 6 is indicative of critical limb ischemia (CLI).9
Category 0: Asymptomatic
Category 1: Mild
Category 2: Moderate
Category 3: Severe
Category 4: Ischemic rest pain
Category 5: Minor tissue loss (i.e. non-healing ulcer, focal gangrene)
Category 6: Major tissue loss (i.e. above the transmetatarsal level)
Critical limb ischemia is persistently recurring rest pain that requires regular analgesia and typically presents with non-healing ulceration or gangrene of the foot or toe and the threat of limb loss or tissue loss.