Considering Vascular Workup Options For The Podiatric Patient

Does the patient really have a pedal pulse or am I just feeling my own digital pulse? Is my patient’s calf pain due to claudication or might they have a deep vein thrombosis (DVT)? These are some questions we find ourselves asking more than we would like to admit when consulting on a new patient. In reality, a significant portion of patients whom we as podiatric surgeons care for deal with some level of peripheral vascular disease. The challenge being that the etiology of our patients' malaise is not always easy to elucidate clinically. In our experience, all podiatric surgeons, whether in residency training or with seasoned clinical experience, should have a low threshold of tolerance for performing advanced diagnostic vascular tests. When dealing with a patient with any underlying comorbidities, an evaluation of arterial perfusion is critical if there are any concerns with infections and wounds.

Consider a healthy middle-aged patient who presents for a consultation about a painful bunion. The patient has little pertinent past medical history, or maybe has hypertension or hyperlipidemia, both well-controlled with medication, and no history of tobacco use. In the presence of palpable pulses, most of us would not consider this patient at significant risk for peripheral arterial disease, and not pursue advanced diagnostic testing. If this same patient now has very weak or non-palpable pulses and perhaps also complains of intermittent claudication or rest pain, then this demands further investigation prior to elective surgery for fear of developing a post-operative wound complication. Once one establishes the presence of an adequate ankle-brachial index with good digital perfusion by arterial Doppler examination, then one should feel safe to proceed with surgery, in our experience.

Now, consider a middle-aged patient with diabetes who presents to the emergency department for cellulitis and an abscess to the foot. This patient may not have palpable pedal pulses at all. How do we prioritize arterial insufficiency in the face of a serious infection? Regardless of vascular status, the presence of active infection will likely prevent any vascular intervention for fear of impending sepsis if this is not already the case.  Urgent infection control takes priority with surgical incision and drainage.  Postoperatively, the surgeon should pack the wound open and then vascular work-up begins, including possible intervention. Once adequately addressing vascular status, then delayed primary closure or definitive amputation can take place. Having a good working relationship with your vascular team is paramount for coordinated team approach in patient management that will optimize patient outcomes as well as potentially decrease length of stay.

When treating patients in an outpatient setting, vascular testing options are often limited to Doppler ultrasound and angiogram. If there is a serious concern with perfusion issues that may compromise wound healing, then it is best to consult your vascular colleague for clearance before proceeding. The patient should be appreciative of the concern and attention towards optimizing surgical results. The risk of a postoperative complication or lawsuit is not worth skipping this simple step.

Understanding vascular options in your community is also important. In southeast Michigan, interventional cardiologists dominate the lower extremity revascularization arena. Recently, we are starting to see more vascular surgeons performing endovascular and open bypass procedures. In other communities, interventional radiologists may be more involved with the lower extremities.  Studies show dramatic improvement with lower extremity endovascular procedures in lowering amputations and limb loss.^1-7

The Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) study provided evidence that endovascular procedures provide some benefits over open bypass procedures in treating lower extremity arterial disease in a randomized clinical trial.¹ Two-year survival rates were 50 to 90 percent in the endovascular treated group.¹ Endovascular procedures were less expensive and showed lower morbidity rates in comparison to open bypass procedures.^2,3  However, the BASIL study also noted better long-term results with open bypass procedures beyond three years.⁴

There are other studies showing better outcomes in certain cohorts either with open bypass or endovascular procedures.^5,6 With conflicting outcomes, I would recommend letting the experts in the field sort out what is best for the patient. However, this can be limited by which disciplines are available. When only one specialty is available, the decision is already made. Trying to determine which discipline to send your patient to, while navigating the politics in your medical community, can be complicated and have referral pattern consequences. An analysis using Florida hospital discharge data from 2005 to 2009 showed that the majority of lower extremity endovascular procedures done by vascular surgeons are for critical limb ischemia whereas the majority of patients treated by interventional cardiologists are for intermittent claudication.⁷ Knowing the specialists and their expertise, regardless of their specialty, is vital to successfully determining who is best to determine the best interventional procedure.

Recently, we have noted more local vascular surgeons with expertise in both endovascular and open techniques. For medically complex patients, I am personally more inclined to refer to vascular surgery for balancing comorbidities and risk-assessment in determining which procedure to pursue. Fortunately, the vascular and interventional cardiology teams work well with each other in our area and I do not have to feel guilty referring to one over the other. Preserving surgeon-patient relationships, if they already see an interventional cardiologist, and navigating the political minefield can complicate the decision on which specialist to consult. However, patient safety should be priority over all else. Sometimes a quick phone call to one of your options may quickly help make that decision. It is best to have good referral options when it comes to managing arterial disease and have an understanding of their capabilities. In the end, patients will receive appropriate care and optimized outcomes.

Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, MI. He is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President-Elect of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.

Dr. Lefler is a third-year podiatric resident at McLaren Oakland Hospital in Pontiac, MI.

References

1. Bradbury AW, Adam DJ, Bell J, et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL) trial: a survival prediction model to facilitate clinical decision making. J Vasc Surg. 2010;51(5S):52S-68S.

2. Bradbury, AW, Adam DJ, Bell J, et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(5S):5S-17S.

3. Forbes JF, Adam DJ, Bell J, et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL) trial: health-related quality of life outcomes, resource utilization, and cost-effectiveness analysis. J Vasc Surg. 2010;51(5S):43S-51S.

4. Conte MS. Bypass versus angioplasty in severe ischemia of the leg (BASIL) and the (hoped for) dawn of evidence-based treatment for advanced limb ischemia. J Vasc Surg. 2010;51(5S):69S-75S.

5. Dayama A, Tsilimparis, N, Kolakowski S, Matolo NM, Humphries MD. Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease. J Vasc Surg. 2019;69(1):156-163.

6. Darling JD, McCallum JC, Soden PA, et al. Results for primary bypass versus primary angioplasty/stent for lower extremity chronic limb-threatening ischemia. J Vasc Surg. 2017;66(2):466-475.

7. Wallace JR, You T, Marone L, Chaer RA, Makaroun MS. Outcomes of endovascular lower extremity interventions depend more on indication than physician specialty. J Vasc Surg. 2014,59(2):376-383.