By Jeffrey M. Levine, MD, AGSF, and Michael Cioroiu, MD, FACS, CWS
Peripheral arterial disease (PAD) of the lower limbs, in which plaque builds up in the arteries that carry blood to the legs, is an often-overlooked cause of poor wound healing, particularly in elderly individuals. While PAD affects roughly 12% to 14% of the general population, it increases with age, affecting up to 20% of patients older than 75 years. Risk factors include:
• diabetes mellitus
• hypertension
• smoking
• hyperlipidemia
Because it decreases the flow of oxygenated and nutrient-rich blood to the legs, PAD can adversely affect any wound of the lower extremity. If a wound is infected, PAD can prevent optimum delivery of systemic antibiotics, resulting in polymicrobial infections and advancement to osteomyelitis (bone infection).
Prevention
Many complications related to PAD can be prevented with basic foot care, control of risk factors, timely treatment of ulceration, and collaboration between nutritionists, nurses, physicians and other specialists, such as podiatrists and vascular surgeons. Persons with PAD also have increased prevalence of vascular events elsewhere in the body, such as heart attack or stroke, making control of risk factors a priority.
Wound care is important, and treatment of any lower extremity wound involves:
• Proper wound cleansing
• Moisturizing cream for dry and flaking skin
• Removal of dead tissue
• Antimicrobial medicine if indicated
• Judicious choice of advanced wound healing dressings
Symptoms
The typical symptom of a wound resulting from PAD is pain; however, lack of pain does not rule out arterial disease as a contributor to poor wound healing. The classic symptom of PAD is muscle cramps that occur in the legs (usually the calf area) when walking. The pain can be mild or severe, and usually goes away with rest. People who walk slowly or are wheelchair-bound due to musculoskeletal disease may not have muscle cramps, but can still have advanced PAD. Pain in the limb at rest, advanced ulceration or gangrene is categorized as critical limb ischemia (severe blockage in the arteries of the lower extremities) and may lead to limb loss if revascularization (a procedure to restore blood flow) is not considered.
Diagnosis
Diagnosing PAD in a patient with a non-healing wound is important, as improvement in arterial perfusion (delivery of nutrient-rich blood) promotes wound healing. Diagnostic tests may include basic blood work, biopsy and non-invasive vascular studies (procedures used to assess the blood volume and flow in arteries and veins).
Treatment
If non-invasive vascular studies suggest a patient has blockage in the arteries of the legs, chances of wound healing are greatly reduced. Once diagnosed, treatment can begin with antiplatelet therapy (medicines that stop blood cells from sticking together and forming a blood clot), vasodilators (medications that open blood vessels), statins (cholesterol-lowering drugs), and lifestyle changes, such as weight loss and smoking cessation.
Surgical therapies to restore blood flow, such as endovascular procedures (performed inside the blood vessels) or vascular bypass grafting (procedure to redirect blood flow around an area of blockage) must also be considered.
The rapid advances in catheter-based technology and minimally invasive vascular procedures through the skin have drastically decreased the use of open surgical bypass revascularization. Endovascular revascularization avoids additional wound healing problems related to vein harvesting and other surgical incisions, and promotes shorter hospital length-of-stay.
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