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Foot Pressure Ulcers: In Patients with Peripheral Vascular Disease (PVD)/ Peripheral Artery Foot Pressure Ulcers: In Patients with Peripheral Vascular Disease (PVD)/ Peripheral Artery

Foot Pressure Ulcers: In Patients with Peripheral Vascular Disease (PVD)/ Peripheral Artery - PowerPoint Presentation

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Foot Pressure Ulcers: In Patients with Peripheral Vascular Disease (PVD)/ Peripheral Artery - PPT Presentation

Erin Moore Clinical Problem Solving I Clinical Question Is peripheral vascular disease peripheral artery disease a valid prognostic factor for determining the healing process of foot pressure ulcers in an 80 year old man ID: 637520

vascular foot healing pressure foot vascular pressure healing patient surgery pta patients disease ulcer blood time ulcers peripheral severe

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Slide1

Foot Pressure Ulcers:In Patients with Peripheral Vascular Disease (PVD)/ Peripheral Artery Disease (PAD)

Erin Moore

Clinical Problem Solving ISlide2

Clinical Question:Is peripheral vascular disease/ peripheral artery disease a valid prognostic factor for determining the healing process of foot pressure ulcers in an 80 year old man?Slide3

Patient History:Age: 81 year oldGender: Male

Admitted to Hospital:

unstable

BP, positive orthostatic hypotension

Orthopedic Surgeries:

L TKR in 2011, R TKR in 2015

Comorbidities:

Hypertension

Osteoarthritis of knee: Left TKR 2011

Hyponatremia

Acute blood loss anemia

Pressure SoreSlide4

Patient History:Mechanism of Injury

Prior to admission to acute care:

R TKR

Discharged to SNF

Wounds developed in SNF:

R

ight dorsal foot

Right calf due ace bandageBilateral heel blistersLeft heel partial thickness wound

Prior

Activity

Levels to R TKR:

Independent

with ambulation and

ADLs

Response to previous PT

After R TKR not participating in PT at SNF

Current Medications

Warfarin (Coumadin) 4mg

daily

Treats high blood pressure

Lisinopril (20 mg tablet)

Amlodipine (2.5 mg tablet)Slide5

Initial Examination:Vitals: Day1

Position

Blood Pressure (mmHg)

Heart

Rate (bpm)

Supine

114/73

92

Sitting

87/68

(Orthostatic Hypotension)99Sitting with LE Exercises112/80100Standing 65/51(Orthostatic Hypotension)~Supine123/76100

Blood

pressure may be effected

by calcification

in arteries or

veins

Potential atherosclerosis could be affecting BP and vascularization in the lower extremitySlide6

Test and Measures:Ankle Brachial Index (ABI)

Noninvasive way to check risk for peripheral artery disease

Calculation of ABI:

Patients measured ABI:

0.49

Severe Arterial Disease

Reason patient sent to

catherization lab

ABI Value

Interpretation

Recommendation

Greater than 1.4Calcification/Vessel HardeningRefer to vascular specialist1.0-1.4NormalNone0.9-1.0

Acceptable

None

0.8-0.9

Some Arterial Disease

Treat risk factors0.5-0.8Moderate Arterial DiseaseRefer to vascular specialistLess than 0.5Severe Arterial DiseaseRefer to vascular specialist

Right ABI

=

Highest SBP of arteries in Right

foot

Highest SBP in both armsSlide7

Intervention and Outcomes:InterventionBed Mobility

Reduce pressure sores

Poor blood flow can cause pressure ulcers

Transfer Training

Gait Training

Therapeutic Exercises/ Activities

Reaching out BOS support improve balance

Marching in place increase strength of muscle, which in turn help blood flow, and maintain knee ROM post-surgeryPatient Goals

Functioning Independently

Outcome

Not certain of patient full progression

Not discharged while present at hospital Last day I saw patientPreparing for catheterization laboratory due to calcification in lower extremitySlide8

Impairments/ Activity Limitation/ Participation Restrictions:Impairments

Unstable Blood Pressure: Orthostatic Hypotension

ABI indicative of severe arterial disease

BLE pain from pressure sores

Right heel more painful

Activity Limitations

Unable to go from sit to stand Independently

Unable to tolerate 1 minute standing, independently min A x 2Unable to ambulate 3 feet independently- requires min A x 2 and RWParticipation RestrictionUnable to drive and care for his wifeSlide9

Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients:

Prospective study

of individuals with diabetes, foot ulcers, and severe PVDSlide10

Methods: Study Population1151 patients were includedAverage Age: 75

61% males

Patients with diabetes, foot ulcers and severe PVD

Followed every patient 5 years after interventionSlide11

Methods: Inclusion CriteriaDiabetes mellitus and foot ulcer and systolic toe pressure <45 mm Hg, a systolic ankle pressure <80 mm

Hg

Non-palpable

foot

pulses:

Wagner

grades 4-5 or pain at

restGrade 4: forefoot gangreneGrade 5: Full foot gangreneAll patient fulfilled Fontaine grade 4Ischemic ulcers or gangreneSlide12

Methods: Doppler Inclusion Criteria:Systolic

toe and ankle blood pressure was measured using

Doppler

techniques

High frequency sound waves used to measure amount of blood flow in arteries and veinsSlide13

Vascular Interventions:Angiography vs no angiographyAngiography: X-ray of blood or lymph vessels, after introduction of radiopaque substance

No Vascular Intervention after angiography

Medical treatment

provided

Percutaneous Transluminal Angioplasty (PTA)

Open up a blocked blood vessel, w/ small flexible plastic tube or catheter with balloon at end of it

Reconstructive Vascular Surgery

Angiography

PTASlide14

Results: Vascular Intervention and Outcome

 

PTA

n=314

Vascular Surgery

n=190

 

n

%

n

%

Primary healingn=415121397137

Minor Amputation

n=184

60

19

4524Major Amputationn=14334113116

Deceased

n=310

63

20

35

18

Dropouts

n=60

21

7

4

2

Still under treatment

n=34

15

4

4

2

Outcome in relation to InterventionSlide15

Results:

 

OR (95% CI)

P value

Age < 75 years

1.03 (1.02-1.05)

<.001

Serum Creatine <130 umol/L

1.59 (1.15-2.2)

.005

Ankle pressure > 50 mm Hg

1.62 (1.18-2.23).003No congestive heart failure1.81 (1.26-2.95).01

Single ulcer vs multiple ulcers

2.75 (1.93-3.92)

<.001

PTA

1.77 (1.24-2.53).02Reconstructive Vascular Surgery2.05 (1.33-3.16).001Ulcer or Wagner grades I-II

2.86 (2.06-3.94)

<.001

PTA and

Vascular

surgery increased the probability for primary healing

without amputation with

an odds ratio of 1.77 and 2.5 respectively

Factors related to ulcer primary healing:Slide16

Conclusion:Factors

that negatively affected the probability of healing.

Comorbidity: congestive heart failure and/or renal disease

Severity of PVD: ankle brachial index

<

50 mm Hg

Extent of tissue involvement: Wagner grades 3-5 and multiple ulcersSlide17

Limitation of Study:Unable to compare outcome of PTA or reconstructive surgery Vascular surgery performed in patients not feasible for PTA

Negative Selection Bias

Patients admitted to university-based foot center

Possibility ulcers treated in primary health care without knowledge of foot teamSlide18

Application to Patient:Median Age in Study: 75

Patient: 81 years old

Increased likelihood of having PTA or vascular reconstructive surgery due to:

ABI indicative: Severe arterial disease

If patient has a procedure such as PTA or vascular reconstructive surgery

Prognosis: Odds ratio of primary healing, goodSlide19

Early Revascularization after Admittance to Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with DiabetesSlide20

Methods: Study Population478 patients prospectively includedDiabetes, foot ulcers, and severe

PAD

Average age: 74

yo

Male: 60%

Treated and followed by a multidisciplinary foot team

Continuous follow up until healing or deathSlide21

Methods:Inclusion CriteriaPatients with diabetes mellitus, foot ulcer and a systolic toe pressure <45 mm Hg and or systolic ankle pressure < 80 mm Hg

(Doppler techniques)

Non-palpable foot pulses with an ulcer Wagner grade 4-5 or pain at rest

Rest pain: Severe persistent pain localized to foot and relieved by dependency

All patients were Fontaine grade

4

Exclusion Criteria

Patients who did not have invasive revascularizationSlide22

Methods: Study DesignEither had percutaneous transluminal angioplasty (PTA) or reconstructive

surgery

PTA not feasible, surgery next option

Time to revascularization calculated

First visit to diabetic foot centerSlide23

Results: Probability of ulcer healing without major amputation

Relation to time to revascularization

Relation to maximal tissue destruction reached during follow-upSlide24

Results:Time to revascularization

No difference between patients who had PTA or reconstructive surgery regarding ulcer progression

Median Healing time

10 months

Factors affecting the probability of healing over time

 

HR (95% CI)

P

Intermittent Claudication

1.64 (1.26-2.13)

<0.001

Peripheral edema0.76 (0.58-0.98)0.033Max. Wagner grades < 3 reached1.92 (1.50-2.50)<0.001

Time to intervention < 8 weeks

1.96 (1.52-2.52)

<0.001Slide25

Conclusion:Factors affecting probability of healing without major amputationShorter time to revascularization

Extent of tissue destruction

Peripheral edema

Intermittent claudicationSlide26

Limitations to Study:Decision for vascular intervention at the discretion of vascular surgeonNo control group

Either received PTA or reconstructive vascular surgery

Time to revascularization calculated from first visit with foot team

Foot ulcer onset is usually unknownSlide27

Application to patient: Average Age 74 yo

Patient: 81

yo

After catheterization lab results?

Depending on degree of calcification may determine whether patient needs PTA or reconstructive vascular surgery

Median healing time 10 months

Prognosis: Fair due to length of healing time

Patient does have son that is available 24/7 Patient motivatedSlide28

Conclusion:Why is this important to PT?As clinicians able to perform ABI

Analyze results

Make physician aware of results

Severe arterial disease

Effects progress of pressure ulcer healing

May deter patient from ambulation, due to pain

Perform exercise that avoid pressure on ulcer

Clinical Question?PAD and PVD negative impact on healing process of foot ulcerHealing time potentially 10 months

motivation of patient?Once patient has surgery the importance of mobility to increase blood flow

Is peripheral vascular disease/ peripheral artery disease a valid prognostic factor for determining the

healing

process of foot pressure ulcers in an 80 year old man?Slide29

Resources:Apelqvist, J.,

Elgzyri

, T., Larsson, J.,

Londahl

, M., Nyberg, P., Thorne, J. (2011). Factors related to outcome of

neuroischmeic

/ischemic foot ulcer in diabetic patients. Journal of Vascular Surgery, 53(9), 1582-1588.

Retrieved from http://www.sciencedirect.com/science/article/pii/S0741521411002990Apelqvist, J.,

Elgzyri

, T., Eriksson, K., Larsson, J., Nyberg, P., Thorne, J. (2014). Early Revascularization after Admittance to a Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes. European Journal of Vascular and Endovascular Surgery, 48 (7), 440-446.

Retrieved

from http://www.sciencedirect.com/science/article/pii/S1078588414003876Imageshttp://www.southpalmcardiovascular.com/florida-vein-specialists-explain-the-ankle-brachial-index-test-and-how-it-is-used-to-detect-vascular-disease/http://www.worldwidewounds.com/2001/march/Vowden/Doppler-assessment-and-ABPI.htmlhttps://www.drmcdougall.com/misc/2006nl/sept/angio.htm (Angiography)http://www.nature.com/nrcardio/journal/v4/n12/fig_tab/ncpcardio1035_F6.html (PTA)Slide30

Questions?