Saving Limbs: Collaboration Between Podiatrists, Interventionalists a Key

July 27, 2017

Breakfast Symposium 1: PVD/PAD
Friday, July 28
7–8:30 a.m.
Presidential A

The five-year mortality rate for patients with diabetes who lost a leg is skyrocketing, even though limb salvage techniques have greatly improved. A vascular surgeon and a podiatrist will explain how a partnership between the two specialties and recent surgical advances could reverse that trend.

In “PVD/PAD,” Alan J. Block, DPM, MS, will review the role of podiatric physicians in the early detection of peripheral vascular disease (PVD) and peripheral arterial disease (PAD).Christopher J. LeSar, MD, will explain how surgeons are having greater success at clearing occluded arteries.

“About 15 years ago, interventional cardiology and interventional radiology figured out that podiatrists are on the forefront of seeing these diseases in an early state. What we were not aware of is that they have these techniques to really do early intervention on these patients,” said Dr. Block, of Columbus Podiatry & Surgery, Columbus, OH. “If we can intervene earlier, the patient stands a better chance of keeping the toes or the foot or the leg.”

The role of the podiatrist is to detect early signs of vascular disease while performing physical exams on patients. Tissue tone, hydration, flexibility, and flowability are key indicators to focus on, he said.

“I call it the rebound of the tissue,” Dr. Block said. “If I see any signs of vascular disease, I get a vascular workup on the patient. If we do find problems, we go to the next test immediately.”

The next step could be an ankle-brachial index test, but a challenge is that many patients have diabetes and neuropathy, so they are unaware of pain and the problem.

“A lot of these patients can’t express pain, and a lot of us are waiting on them to tell us they hurt,” Dr. Block said. “They can’t see it, they can’t feel it, and they can’t express it, so we ignore it, and they ignore it. Therein lies the problem. I want to know as soon as possible if they are having a problem. A better result happens because we got to it quicker.”

Better results also are becoming more common because of advanced interventional techniques. Dr. LeSar will review the physiology of arterial circulation in the lower extremities and the feet, as well as the use of the angiosome concept during interventions.

“I will explain the physiology by using case examples. We will talk about how we reconstruct arteries and why we are reconstructing certain arteries. It is a how-to approach on arterial reconstructions,” said Dr. LeSar, a vascular surgeon at the Vascular Institute of Chattanooga, Chattanooga, TN.

Interventional options start with the simplest procedure, which often is accessing the superficial femoral artery through the groin to clear occluded arteries. If the problems are greater in the lower extremities, a pedal approach is an option.

“Coming from below ankle level is one of the escalation steps. It is an evolving concept and technique, but when you use it, it tends to get you to the next level,” Dr. LeSar said. “Sometimes it is the only option. We have done reconstruction where the arteries are all completely blocked, but we can still get them open.”

Another topic will be the idea of the “perfect storm,” in which patients with diabetes have low circulation, then get into greater danger with infected wounds that will not heal. That is where a team approach is important, he said.

“Limb salvage is absolutely a collaborative approach. Multiple disciplines are needed to heal wounds and to save the leg,” Dr. LeSar said. “It is not just about a podiatrist or a surgeon doing his thing. It has to be a collaborative approach if we are going to be more successful in treating these problems.”

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