Keys To Comprehensive Care For A Patient With Critical Limb Ischemia

Emphasizing multidisciplinary care, this author focuses on getting a 56-year-old patient ambulatory following a transmetatarsal amputation related to critical limb ischemia.

By this time, most of us who have dedicated our professional careers to lower extremity preservation and unnecessary amputation prevention comprehend all that peripheral arterial disease (PAD) and critical limb ischemia (CLI) entail.

Consider the five-year mortality rates of PAD and CLI in comparison with various cancers, the odds of amputation of the contralateral limb, and the bleak likelihood of ever ambulating with a prosthesis, not to mention the undignified downward spiral this group of patients experiences before departing this life.^1-3 We know what these patients face and it motivates us to prevent such tragedy on a daily basis.

The emergence of technologies engineered to open occluded coronary as well as peripheral arteries has undoubtedly been responsible for extending and improving the quality of life for countless patients, many of them suffering from severe PAD and CLI. Amputation rates are apparently on the decline.² This speaks to the acceptance of the team approach to limb preservation, breakthroughs in devices and the positive impact teams and technology share in this perceived improvement.

A Closer Look At The Patient Presentation

A 56-year-old Hispanic female presented in March 2015 following the new onset of a “bruised left leg” three days earlier. The patient has diabetes as well as an extensive tobacco history, but had stopped smoking five days earlier. Her medical history also includes essential hypertension, hypercholesterolemia, congestive heart failure, deep venous thrombosis and PAD. Her surgical history includes a coronary artery bypass graft in 1997, carpal tunnel and back surgeries in 1997, and amputation of the left hallux in 1997. 

The vascular technician discovered high-grade stenosis of the left proximal to mid superficial femoral artery and high-grade stenosis of the proximal left profunda with additional findings of blockage at the anterior tibial artery, dorsalis pedis and the posterior tibial artery. The left leg was cold, toes were ischemic and dry gangrene was present with slough of skin and extensive soft tissue necrosis visible. The patient had intractable pain.

An interventional cardiologist performed an immediate endovascular procedure. Procedures included atherectomy of the left proximal superficial femoral artery occlusion and placement of a 7 x 100 mm drug-eluting stent at the mid-superficial femoral artery. Brisk flow was evident post-procedure with the left foot supplied by the peroneal artery and the distal peroneal artery supplying a patent plantar artery.

I performed a transmetatarsal amputation as the digits were beyond salvage. The plantar aspect of the foot remained viable while areas of slough along the dorsum of foot and anterior ankle progressed to eschar in the subsequent weeks following the procedures. 

On the podiatry side, I managed the patient for wound care on a weekly outpatient basis with home nursing providing dressing changes as I directed. She received regular debridement of the wound, including excision of eschar upon demarcation of the contrasting presence of underlying viable tissue, as well as five applications of a living skin substitute, Apligraf (Organogenesis). Additionally, the wound bed preparation prior to skin substitute application was 0.25% Dakin’s solution-moistened calcium alginate. 

The patient is on dual anticoagulation therapy and has a regular arterial ultrasound every three months. I have continued following her on a weekly to biweekly basis with regular handheld Doppler evaluation during wound care visits. She is now weightbearing and has begun gait training with anticipation of full weightbearing in diabetic shoes/inserts in the near future.

Dr. Bell is a board-certified wound specialist of the American Board of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder and President 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.

References

1. Armstrong DG, Wrobel J, Robbins JM. Are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286-287.

2. American Diabetes Association. National Diabetes Fact Sheet 2011. Available at https://www.cdc.gov/diabetes/pubs/pdf/methods11.pdf .

3. Allie DE. New advances in critical limb ischemia. The staggering clinical and economic cost of CLI. Presented at New Cardiovascular Horizons CLI Summit, Miami, 2006.