A Multidisciplinary Approach to CLI is Essential Wound

A Multidisciplinary Approach to CLI is Essential: Wound Care, Risk Factor Modification, and Endovascular Therapy James P. Zidar, M. D. , F. A. C. C. , F. S. C. A. I Clinical Professor of Medicine UNC Health Systems Corporate Chief of Cardiology, Rex Healthcare President, Rex Heart and Vascular Specialists Raleigh, North Carolina

James P. Zidar, MD Grant Support: Cordis Corporation Honoraria: Medtronic Core. Valve Abbott Vascular

PAD …. What are the goals? • Asymptomatic – treat risk factors • Claudication – medical therapy or revascularization to • improve symptoms Critical Limb Ischemia – prevent amputation and limb loss

Risk Factors for PAD • Diabetes • Smoking • Disproportionate prevalence in African Americans • Slightly higher prevalence in males • Increasing age • Hypertension • Dyslipidemia • Inflammatory markers • Hyperviscosity and hypercoagulable states • Hyperhomocysteinemia • Chronic renal insufficiency TASC II. Journal of Vascular Surgery, January 2007

Limb Loss • Non-diabetics have a “relatively low” risk of either abrupt deterioration (20%) or amputation (<10%) • Diabetes increases risk of amputation 6 X • Smoking increases risk 11 X

Disease Patterns Non-Diabetics

Diagnosis • Non-invasive • Bedside Ankle-Brachial Index • Lower extremity Segmental Pressures • • • and PVRs Arterial Duplex imaging MRA CTA • Invasive • Angiography

Assessment - baseline Non-Invasive Studies Include: • Ankle Brachial Index (ABI) • Toe Brachial Index (TBI) • Segmental Pressures • Pulse Volume Recordings (PVR) • Waveforms • Arterial Ultrasound • Tc. PO 2 • Skin Perfusion Pressures (SPP) National guidelines-indicate necessity to rule out arterial disease with ABI/TBI for any patient with a lower extremity ulcer. American Diabetes Association suggests all diabetics >50 years of age be evaluated for PAD

Arterial Ultrasound Continuous-Wave Doppler Ultrasound • Assess lower extremity PAD anatomy, severity, and progression • Provide localizing information in patients with poorly compressible arteries • Quantitative data after successful lower extremity revascularization Image downloaded from: http: //www. pacificvascular. com/images/technical. LEAlarge. jpg December 2008 Duplex Ultrasound • Establish the diagnosis of lower extremity PAD and its anatomic location • Define severity of focal extremity arterial stenoses • Select candidates for endovascular or surgical revascularization

Transcutaneous Oximetry (Tc. PO 2) • Determines the degree of microvascular/tissue perfusion of an area • Predictor of Wound Healing • Normal on room air - 50 -90 mm. Hg • Abnormal - 40 -50 mm. Hg • Clinically significant impaired wound healing <40 mm. Hg

Basic Treatment of CLI • Medical Rx- ASA, Ace inhibitor, statin, ? clopidogrel, ? Pletal, • Pin control • Management of ulcer and gangrene • Infection control • Local Rx & pressure relief • Revascularization • Amputation

Revascularization of Critical Limb Ischemia - Intervention ØEndovascular Procedures: ØPercutaneous Transluminal Angioplasty (PTA) ØStents ØAtherectomy ØExcisional ØLaser Ø“Specialized” Angioplasty Devices ØCutting and Scoring Balloons ØCryoplasty ØPossibly Drug eluting balloon

Lifestyle changes • Avoid: leg crossing, trauma, cold, friction, constrictive clothing, moisture between toes, bare feet • Routine professional foot care • Foot wear to off-load high risk pressure areas • Supervised walking program • Avoid sedentary lifestyle • Nutritious diet regimen

Arterial Ulcer Care Reinstate arterial flow - key to wound healing Then… - Adequate debridement - Dressing choice based on wound needs • Treatments that stimulate angiogenesis • Negative Pressure Wound Therapy • Biologic products • Bioengineered tissues • Growth factors • Hyperbaric Oxygen Therapy NHC Marketing Library

Who Staffs Our 3 Wound Healing Centers • 10 physicians-each staff ½ day per week • 5 general surgeons • 1 plastic surgeon • 1 orthopedic surgeon • 2 vascular surgeons • 1 podiatrist • Eliminate financial silos- incent group behavior

Hyperbaric Oxygen Therapy Benefits • Decreases edema through vasoconstriction • Improves collagen production • Increases tissue oxygenation • Increased oxygen tension facilitates phagocytosis • Promotes neo-angiogenesis • Enhances granulation tissue formation

Requirements of a Successful CLI Program • Excellent primary care screening with widespread baseline non • invasive testing Wound clinic that can see patient weekly for aggressive debridement • • Weekly photos of the wound Hyperbaric chamber • Aggressive endovascular group with an angiosome approach to • • revascularization. Vascular surgery support for the pt who requires open fem-tibial bypass or needs toe or forefoot amp. Eliminate financial silos- incent group behavior

Possibilities….