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
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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?