Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
1
Wound Care for Critical Limb
Ischemia
Michael Maier, DPM, FACCWS
Cardiovascular Medicine
Cleveland Clinic
North Central Heart
Vascular Symposium
May 6, 2016
Disclosures
Speaker, Smith & Nephew
OBJECTIVES
• Discuss various clinical presentations of patients with critical limb ischemia (CLI)
• Review principles of wound care and limb salvage
• Illustrate comprehensive management strategies for patients with CLI and tissue loss
PAD Clinical Presentations
• Asymptomatic: 20 – 50%
• Classic Claudication: 10 – 35%
• Atypical Leg Pain: 40 – 50%
• Critical Limb Ischemia (CLI): 1 – 2%
McDermott et al. JAMA 2001;286:1599.
CLI – Clinical Definition
Fontaine Classification
Stage I
• Asymptomatic
Stage II
• IIa – Claudication > 200m
• IIb – Claudication < 200m
Stage III
• Rest pain
Stage IV
• Ischemic ulcers or gangrene
Rutherford Classification
Stage 0
• Asymptomatic
Stages 1, 2, 3
• Mild, moderate, severe claudication
Stage 4
• Rest pain
Stage 5
• Digital ischemic ulcers
Stage 6
• Severe ischemic ulcers or gangrene
TASC Document J Vasc Surg; 2000:S170
CLI – Hemodynamic Definition
• Ankle pressure < 50 – 70 mmHg
• ABI < 0.4
• Toe pressure < 30 – 50 mmHg
• TcPO2 < 30 – 50 mmHg
TASC Document J Vasc Surg; 2000:S170
2
Critical Limb Ischemia
Dependent rubor
Gangrene Tissue loss
What About Timing?
• 63 year diabetic man presents with a painful toe blister
TBI 0.23
4 weeks later…
• Multiple attempts to recanalize severe infrapopliteal arterial disease
• Ischemic rest pain
• Isolated 4th toe amputation
• Marked decline requiring BKA
• 68 year old man with ischemic cardiomyopathy, CHF, MI, A-fib, CAD s/p CABG x 4, and mitral valve disease
• Severe foot pain attributed to multifactorial leg edema
3
Aortoiliac Reconstruction
4 Weeks Post-intervention 14 Weeks Post-intervention
• 70 year old diabetic man with renal transplant
• Multiple revascularizations
• Ischemic necrosis and amputations of multiple fingers
PAD with critical limb ischemia
• 60 year old diabetic man with ulcerated heel blister
• Remote non-traumatic left BK and right 1st ray amputations
• Remote R popliteal artery thromboendarterectomy
ABI: 0.76
4
2cm depth
Diagnostic Angiogram
Post Intervention Angiogram
• 82 year diabetic lady with bilateral midfoot collapse due to Charcot arthropathy and partial 1st ray amputations
• Presents with left midfoot ulceration x 1 month
ABI: 0.56
Left popliteal artery intervention
5
ABI: 1.12
ABI: 0.56
• Post-intervention sharp and enzymatic debridement
• Non-weight bearing
3 weeks later…
7 Weeks Post-Intervention
12 Weeks Post-Intervention
Angiosome Approach to Perfusion
6
4 Weeks Post-Repeat Intervention
8 Weeks Post-Repeat Intervention
16 Weeks
Post-Repeat Intervention
21 Weeks
Post-Repeat Intervention
3 Month Follow Up
Infection Control
• Do not leave dressings in place for extended periods
• Adjust dressing change frequency according to volume of drainage
Wound Infection
• Erythema • Calor • Tissue edema • Drainage • Pain* • Fluctuance • Depth
Deep vs Superficial cultures
7
Infection Control
• Utilize imaging (x-ray, MRI, CT scan) to assess extent of tissue involvement
Infection Control
• Clinical signs of infection may be muted in diabetic patients
• 62 year old man
• Severe diabetes, HTN, HL, borderline CKD (CR 1.4)
• Non-traumatic right BKA
• Calcaneal osteomyelitis
• Treated with IV Vanco + Zosyn
• Aggressive wound treatment
– HBOT
– Advanced topical therapies
– Offloading
ABI: 1.17
TBI: 0.21
ABI: 0.69
3 weeks 7 weeks 10 weeks
Clinical Course Angiogram
8
2 Weeks Post-intervention
• Sharp debridement
• Initiate enzymatic debridement
6 Weeks Post-intervention
14 Weeks Post-intervention 10 Weeks Post-intervention
• Continue enzymatic debridement
• Initiate NPWT
22 Weeks Post-intervention 19 Weeks Post-intervention
• Hold enzymatic debridement
• Initiate sequential acellular tissue
grafts
35 Weeks Post-intervention
Conclusions
• Perform prompt intervention for CLI to optimize healing potential and improve outcomes
• Complete thorough wound assessment to identify and treat infection
• Reserve aggressive debridement and compression therapy until after perfusion is optimized
Thank You