Reporting on the Current and Future Trends in Vascular and Wound Care
At the 2023 Symposium on Advanced Wound Care Spring, Vickie Driver, DPM, MS, FACFAS, and Richard Neville, MD, FACS, DFSVS, spoke on the topic of vascular and wound care in their rapid fire session, “Current and Future Trends in Vascular and Wound Care.”
In Dr. Driver’s portion of the session, she discussed the 5-year mortality rate of diabetic foot complications, amputation prevention, and key invasive steps and procedures that are common in advanced wound care. According to Dr. Driver, “up to one-third of half of a billion individuals with diabetes worldwide will develop a foot ulcer during their lifetime.” More than half of those diabetic foot ulcers (DFUs) will develop an infection, and 17% of those will require an amputation. With the greatest risk factor for a DFU developing being a previously healed DFU, these are a silent, leading cause of disability worldwide. When it comes to amputation prevention, it was commented that the practitioner must utilize aggressive management of critical limb ischemia (CLI) and infections, develop a multidisciplinary care team and a stratification system for the risk level to promote quick access to care, and provide patient-centered educational materials. Dr. Driver also noted that the common pitfalls in saving feet include a failure to recognize ischemia, eradicate infection, restore function, redistribute pressure, and achieve primary closure. However, the lack of follow-up and treatment visits are a large pitfall. Dr. Driver said, “These patients, when they have procedures, … need to come back to the wound center and followed but the people who really know them and how to treat them.”
When evaluating the patient, it is important to know that the risk factors for a DFU developing consist of general or systemic contributions (ie, uncontrolled hyperglycemia, diabetes duration, peripheral vascular disease, blindness or vision loss, advanced age, or chronic renal disease) and local issues, such as peripheral neuropathy, structural foot deformity, and history of prior ulceration or amputation to name a few. The disease severity must also be evaluated—skin/ulcer, infection, vascular, neuropathy, deformity, and etiology. There are a multitude of reasons that progression may occur, which can include a lack of understanding to the seriousness of the problem, lack of at-home care or assistance, lack of check-ins with trained providers, poor nutrition, untreated common pathologies, lack of urgency, and most importantly, only the symptom, not underlying problem, is treated.
Decreasing pressure in areas of increased pressure, removing infected bone, closing difficult wounds, careful timing, and restoring functional stability are some of the key goals of care, commented Dr. Driver, when encountering a patient with vascular and wound care needs.
The second half of the session was presented by Dr. Neville in which he covered how to evaluate the vascular status of a patient, including the symptoms, examination, and diagnostic studies to order; the revascularization procedures available for wound healing; and an emphasized focus on arterial disease to determine the difference between venous and arterial disease. Dr. Neville provided an understanding of peripheral arterial disease (PAD), including the increasing trend (>10 million Americans, an additional 1 million new Medicare patients annually, and one-third of patients > 70 years) and increased risk of death from stroke or heart attack. In speaking on the vascular pathology of the lower extremity, Dr. Neville noted that there is a misconception of microvascular disease not being amenable to revascularization. He also said, “people may say we can’t save the limb, but we can. … Don’t think that nothing can be done.”
Another important factor Dr. Neville shared was the disparity of care delivered in PAD treatment and care. He noted that racial and ethnic disparities in the treatment of PAD exist, with people of African American and Hispanic ethnicities more likely to have a delay in treatment and thus seen in the emergency room. His slides also showed the higher risk of mortality in these patient populations that stem from PAD. African Americans, he said, are 2 times as likely to have an amputation and Hispanic individuals are 50% more likely to receive an amputation.
Dr. Neville went on to describe 2 symptoms of PAD: claudication and critical limb-threatening ischemia (CLTI). Treatment trends for CLTI include endovascular and surgical interventions. The physical exam, he noted, should include a pulse exam (femoral, popliteal, and dorsalis pedis and posterior tibial) and wound location assessment for venous, arterial, or neuropathic etiology. Noninvasive vascular labs should include several factors, some of which are ankle-brachial index, segmental waveforms and pressures, pulse volume recordings, digital pressures, duplex imaging, and tissue perfusion. State-of-the-art imaging includes computed tomography angiography, which should be considered, but there are advantages (no arterial puncture, 3D reconstruction, and calcium shown) and disadvantages (use of contrast and images impeded by calcium). Magnetic resonance angiography, Dr. Neville said, was also a state-of-the-art imaging option. As far as medical therapy for PAD, he mentioned aspirin, pentoxifylline, cilostazol, and clopidogrel are options.
“Vascular therapy is just one tiny piece of this puzzle,” Dr. Neville noted. “This is a team sport … you can’t do it alone.”
-Jaclyn Gaydos, Senior Managing Editor
