LAS VEGAS — Patients with venous leg ulcerations often also have peripheral artery disease and, in these cases, aggressive treatment with a focus on wound care is often warranted, according to an expert at VIVA 16.
The goals for patients with venous leg ulcerations and PAD are to heal the venous leg ulcer, increase the rate of healing and prevent recurrence, while containing costs and improving the patient’s quality of life, Robert B. McLafferty, MD, chief of surgery at Veterans Affairs Healthcare System, Portland, Oregon, and professor of surgery at Oregon Health and Science University, said during a presentation.
The prevalence of patients with venous leg ulcerations and PAD is unknown, but some studies have estimated that approximately one-third of patients with venous disease also have PAD, according to McLafferty. “We’re not really thinking in PAD mode when we see that venous leg ulcer,” he said.
If the ulcer cannot be healed, “sometimes the goal is just to make the wound smaller, prevent it from getting larger, minimize pain and optimize ease of care for those taking care of these patients,” he said.
Patients with venous leg ulcerations should be tested for PAD, edema should be eliminated, bioburdens and infections should be treated, wound care ancillaries should be employed, underlying conditions such as diabetes must be treated, and the venous disease should be treated, according to McLafferty.
Patients with venous leg ulcers should be tested for PAD if they have several of the characteristics of patients with PAD, including smoking, diabetes, hypertension, high cholesterol, end-stage renal disease and a history of CHD or CVD, he said. A comprehensive history of the severity of the venous disease is also helpful.
Presence of common symptoms of venous disease, including pedal pulses, edema, obesity, congestive HF and lipodermatosclerosis, should not be used as excuses not to look for PAD, he said.
Instead, “there’s a spectrum of tests to objectively measure PAD” that should be used, including ankle-brachial index (ABI), McLafferty said. He noted that an ABI > 0.85 indicates that compression therapy will suffice and there is no need for revascularization; an ABI of 0.5 to 0.85 indicates that moderate PAD is likely and a number of options can be considered; and an ABI below 0.5 indicates that revascularization should be the first option.
“For patients with moderate PAD, I think that for patients with venous leg ulcers that are large, ... recalcitrant or ... recurrent, you should be aggressively revascularizing these patients,” McLafferty said.
Patients with severe PAD may need extensive wound care, perhaps at an outpatient nursing facility, he said. – by Erik Swain
McLafferty RB. Pushing the Boundaries. Presented at: VIVA 16; Sept. 18-22; Las Vegas.
McLafferty reports no relevant financial disclosures.