Feature On the cutting edge of wound care


A primer on what every IR needs to know By Omosalewa Adenikinju, MD, Robert E. Beasley, MD, Timothy Yates, MD, and Brandon Olivieri, MD


I


schemic rest pain and tissue loss from atherosclerosis, or critical limb ischemia (CLI), represents the end stage of peripheral arterial disease (PAD). Vascular specialists are trained to recanalize arterial stenoses and occlusions with a high degree of precision. However, managing this systemic disease requires multidisciplinary effort to aid early detection and stratify treatment. In this article, we offer the interventionalist a primer approach on cutting-edge wound care, all of which will take place outside of the angiography suite.


In a normal response to tissue injury, the body’s wound-healing cascade is initiated. The progression begins with an inflammatory phase, which prompts cytokines to invoke a complex cellular response leading to phagocytosis, angiogenesis and granulation tissue.2,3 This is augmented in the proliferative phase as neo-angiogenesis allows delivery of nutrients to the wound and promotes fibroplasia and collagen tensile strength. These steps ultimately lead to complete restoration in the remodeling phase.2


However, this progression is abnormal in the CLI patient. The chronically hypoxic environment promotes prolonged inflammation from oxidative stress, nutrient deprivation, and cytokine and growth factor imbalance. Additionally, there tends to be an excess of proteolytic enzymes such as matrix metalloproteinases, which ultimately perpetuate the nonhealing wound.4,5


20 IRQ | WINTER 2019


Although arterial insufficiency is implicated as a contributing component in many nonhealing lower extremity ulcers, it is important to recognize that advanced venous disease also prevents adequate oxygen and micronutrient delivery to and from the wound bed.4


Given that


many CLI patients have a history of smoking and obesity, they can have mixed arterial and venous pathology. These confounders can augment patient findings, further complicating the picture for the clinician.


Patient symptoms and physical examination can be help differentiate between the two etiologies. Typically, venous wounds are exudative and painless (in the absence of infection), often with surrounding varicosities and edema in the gaiter zones (medial and lateral malleoli). They are usually the sequelae of chronic venous hypertension.6,7


Arterial ulcers, in contrast, arterial ulcers are usually painful and necrotic, affecting the acral appendages (digits), often in the clinical setting of neuropathic, accidental or repeated injury. Employing the “angiosome” concept and other perfusion modalities (e.g., methylene blue, FluoBeam®, HyperViewTM


), we are


able to predict where we can expect to find disease on noninvasive and angiographic studies.


Initial radiographs and cross-sectional imaging (CT/MR) are often obtained to evaluate for osteomyelitis, a common cause for chronic nonhealing wounds that portends a worse


After considering the “typical players,” vascular specialists need to consider other potential causes for treatment failure. One such factor is patient insight. Critical limb ischemia patients need to be enlightened and empowered about the genesis of their wounds and given tools to prevent progression. In fact, the literature has shown that patient insight is critical to combat this disease.9


prognosis. Infection is a factor that increases risk for amputation, according to the Society for Vascular Surgery lower extremity threatened limb/WIfI classification system8


,


thus it must be recognized and corrected promptly.


Typically built on


years of unhealthy lifestyle habits, it takes a great deal of effort to make the lifestyle changes necessary to optimize the wound healing environment.


Lifestyle modifications can be prioritized as follows:


Smoking


• Most important lifestyle modification recommended


• Lower patency rates after revascularization and even higher amputation rates in smokers with PAD10


• Recommendation: Cessation


• Equip patients to change and set objectives to foster desire for an improved quality of life


• Offer resources for behavior change (pamphlets, support groups)


• Medication (e.g., nicotine supplements)


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