2. MidAtlantic Vascular, LLC Critical Limb Ischemia. P.A.D. Detection, Treatment, and Referral Paul Sasser MD FACS

3. P.A.D. and Podiatry Podiatrists are positioned to: Recognize the early and advanced signs of P.A.D. Improve lower limb wound healing rates Reduce lower limb amputation rates P.A.D. is routinely seen in the daily practice of podiatrists The feet can reveal the first signs and symptoms of P.A.D. “Podiatric physicians are commonly the first to thoroughly evaluate a patient’s legs and feet regardless of the patient’s reason for a visit.”

4. Clinical Signs of Limb Ischemia Nonhealing wounds Shiny skin Loss of hair growth Cool skin temperature for one limb but not the other Pale or bluish skin Reduced capillary fill times Pallor on elevation and rubor on dependency

5. Patient presents with Critical Limb Ischemia- What do we do next? We know our complex patients can have multiple comorbidities with similar and often overlapping signs & symptoms Are we looking for all contributing factors?

6. Foot Care and P.A.D. Preventative foot care: Daily foot inspection Skin cleansing and moisturizing Appropriate footwear Promptly address skin lesions and ulcers Podiatric care To reduce the risk of ulcers, infection, necrosis, and amputation, high-risk patients should: Perform proper foot care Receive annual foot exams

7. Classical Diabetic Triad of Pathology PVD Infection Neuropathy

8. Diabetic Foot and P.A.D. Diabetic foot ulcers: 15%-25% of persons with diabetes develop a foot ulcer 14%-24% of persons with a foot ulcer require amputation Foot ulcers precede 85% of non-traumatic amputations About 50% of all foot ulcers are due to P.A.D. Peripheral neuropathy can accompany P.A.D. in patients with diabetes and lead to: Decreased pain perception Sudden ulcer formation

9. Multidisciplinary Care of the Diabetic Foot A joint statement from the Society for Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA) specifies that diabetic foot care requires: Vascular assessment and revascularization, if necessary Wound assessment and staging/grading of ischemia and infection Risk monitoring and reduction for reulceration and infection

10. Limb Ischemia and the Diabetic Foot Critical limb ischemia (CLI) in the diabetic population requires multidisciplinary care Ischemia is one of many factors underlying diabetic foot disease, and leads to: Decreased tissue resilience Impeded wound healing Rapid tissue necrosis Left untreated, CLI results in non- healing wounds and potential amputation

11. Classical Diabetic Foot Treatment Plan Stop Smoking Exercise Achieve Ideal Body Weight Control Blood Pressure Control Diabetes Antiplatelet Therapy Off-Loading Debridement Infection Management Ischemia Management Control Cholesterol and Triglycerides