Peripheral Arterial Disease and Foot Wounds

By Lauren Molchan, DPM R2 - February 24, 2020

Peripheral Arterial Disease and Foot Wounds
By Lauren Molchan, DPM R2 

When do you suspect PAD in patients with wounds? 
·    On physical exam, findings that would indicate PAD include wounds located on the tips of the toes or foot, wounds covered by black eschar or gangrenous changes, shiny atrophic skin, lack of pedal hair or weak or absent pedal pulses. 
·    Past medical history indicators of PAD include: history of smoking, age 65 or greater, diabetes history, CAD or stroke, or history of renal, carotid or mesenteric ischemia. 

What does the PAD workup include? 
·    Detailed history including claudication symptoms, rest pain, diabetes and smoking history, history of renal, carotid or mesenteric ischemia. On physical exam, evaluate pedal pulses, temperature of distal extremities, pedal hair presence, wounds, and if available perform a Doppler exam (a normal result is a strong, triphasic waveform; patients with PAD often have weak and monophasic waveforms). 
·    Keep in mind patients with significant neuropathy may not have typical claudication symptoms. They may describe feelings of their legs “giving out” or “feeling like jelly” that is brought on after walking certain distances and relieved by rest. 
·    If pulses are weak or absent, the next step would be to order non-invasive exams such as ABIs or skin perfusion pressure. Patient’s have an abnormal ABI if the value is lower than 0.9. If the ABI is higher than 1.2 this is an indicator that the vessel is calcified and unable to compressed. In this case, TBIs can be useful since the small vessels in the toe often are unaffected. 

What lifestyle changes and recommendations can I make to my patients with wounds associated with PAD? 
·    Diabetic management is important in preventing the progression of disease. Encourage patient to take an active role in their care and monitor their blood glucose levels and remain compliant with prescribed medications. 
·    Encourage smoking cessation and help provide smoking cessation resources. Smokers have four times the risk of developing PAD as nonsmokers. Smoking cessation not only will help with PAD progression but also reduce risk of other cardiac diseases such as stroke, CAD, MI. 
·    Encourage an active lifestyle. Simple walking or treadmill programs tree times per weeks can reduce claudication symptoms in few as 4-8 weeks. 
·    Monitor patients cholesterol and prescribe statin medications when appropriate. Recommend diets low in trans fats, saturated fats and cholesterol with plenty of fruits and vegetables. Referrals to nutritional programs or specialists can be beneficial. 
·    Ensure appropriate hypertension management and medication. In one study published in JAMA showed patients on appropriate antihypertensive management, specifically an ACE inhibitor, had 60% pain free walking compared to pre-treatment symptoms. 
·    In patients with neuropathy, encourage patients to wear shoes even in the home and perform daily foot exams so they may catch wounds in their earliest stages. 

When should I refer to a specialist? 
·    Patients with non-healing wounds, absent or weak pulses, abnormal ABIs (<0.9), or history of claudication symptoms or rest pain should be referred to a vascular surgeon for further evaluation and possible intervention to improve blood flow. Early intervention in PAD patients can not only provide wound healing benefits but also prevent worsening of disease and prevent limb threatening disease such as critical limb ischemia. 
·    One study found that more than 50% of lower extremity amputations occur without prior vascular testing of any type (including noninvasive testing such as Doppler, PVRs or ABIs). With adequate examination, referral and intervention, many of these limbs could have been saved. (1) 
·    The vascular surgeon can help restore blood flow giving the wound a chance to heal; however, the patient would also benefit from a referral to a wound specialist such as a Podiatrist. 

(1)     Allie DE, Hebert CJ, Lirtzman MD, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI. Euro Intervention J. 2005; 1(1):75-84.
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