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Managing Peripheral Vascular Disease in the Outpatient Setting

Managing Peripheral Vascular Disease in the Outpatient Setting. George L. Adams, MD, MHS, FACC Clinical Associate Professor of Medicine University of North Carolina Health System Director of Cardiovascular and Peripheral Vascular Research, Rex Healthcare. Conflicts/Disclosures.

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Managing Peripheral Vascular Disease in the Outpatient Setting

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  1. Managing Peripheral Vascular Disease in the Outpatient Setting George L. Adams, MD, MHS, FACC Clinical Associate Professor of Medicine University of North Carolina Health System Director of Cardiovascular and Peripheral Vascular Research, Rex Healthcare

  2. Conflicts/Disclosures Consultant/Advisory Board/Research Support/ Educational Services Daiichi Sankyo Cook Medical Cardiovascular Systems Inc. Lake Region Medical Spectranetics Abbott Vascular Terumo Closys

  3. Outline Identifying the patient at risk for limb threatening ischemia What is the role of the wound care clinic? Should endovascular procedures remain in the hospital or move to outpatient centers?

  4. Background • Approximately 8 million Americans over the age of 40 have PAD. • Many people mistake the symptoms of PAD for something else. • PAD often goes undiagnosed by healthcare professionals. Am J of Prev Med. 2007;32:328-334. J Vasc Interv Radiol. 2002;13:7-11.

  5. 44% 29% 56% Patients diagnosed with PAD PAD only PAD and cardiovascular disease Diagnosis of Peripheral Arterial Disease in High-Risk Patients • PARTNERS evaluated 6979 patients in physicians’ offices • Possibility of PAD evaluated in • All patients 70 yr; mean (±SD) age: 70 (±10 yr) • Patients 5069 yr with history of diabetes and/or smoking (at least 10 pack/yr) Only 49% of PAD patients physicians knew they had PAD Hirsch AT et al. JAMA. 2001;286:1317

  6. Prevalenceof PAD

  7. Prevalence of PAD Increases With Age Rotterdam Study (ABI <0.9)1San Diego Study (PAD by noninvasive tests)2 60 50 40 30 Patients With PAD (%) 20 10 0 55-59 60-64 65-69 70-74 75-79 80-84 85-89 Age (years) ABI=ankle-brachial index 1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Criqui MH, et al. Circulation. 1985;71:510-515.

  8. Gender Differences in the Prevalence of PAD 6880 Consecutive Patients (61% Female) in 344 Primary Care Offices 18 16 Women 14 Men 12 Prevalence (%) 10 8 6 4 2 0 <70 70–74 75–79 80–84 >85 Age (years) Diehm C. Atherosclerosis. 2004;172:95-105

  9. 10 9 8 7 6 Fraction of Population With PAD (%) 5 4 3 2 1 0 NHW Black Hispanic Asian Ethnicity and PAD:The San Diego Population Study NHW = Non-hispanic white. Criqui, et al. Circulation. 2005:112:2703-07.

  10. 25 22.4* 19.9* 20 15 12.5 Prevalence of PAD (%) 10 5 0 Normal GlucoseTolerance Impaired Glucose Tolerance Diabetes Diabetes Increases the Risk of PAD Impaired glucose tolerance was defined as oral glucose tolerance test value ≥140 mg/dL but <200 mg/dL. *P.05 vs. normal glucose tolerance. Lee AJ, et al. Br J Haematol 1999;105:648-654.

  11. PADSymptoms

  12. ~15% Classic (Typical) Claudication 50% Asymptomatic ~33% Atypical Leg Pain(functionally limited) 1%-2% Critical Limb Ischemia Clinical Presentations of PAD

  13. Claudication Common and Internal Iliac Arteries– Buttock pain External Iliac Arteries – Thigh pain SFA and Popliteal Arteries – Calf pain

  14. Critical Limb Ischemia Tissue Loss • Multi-level arterial disease plus: • trauma • neuropathy • infection • 50% 2-year mortality • 30% of patients die without healing their wounds

  15. Peripheral Arterial Disease: All-Cause Mortality* 100 Normal Subjects ~40% 10-yr mortality 75 Asymptomatic PAD Patient Survival (%) 50 Symptomatic PAD 25 Severe SymptomaticPAD ~75% 10-yr mortality 0 0 2 4 6 8 10 12 Time (yr) *Majority of deaths due to cardiovascular causes Criqui MH et al. N Engl J Med. 1992;326:381

  16. What is the Role of the Wound Care Clinic? To Help Heal the Wound

  17. Debride = Getting to the ‘Good Stuff’ Hyperkeratotic Tissue Debride = (Fr).’To release or set free’ Cut Here! Tomic-Canic, Ayello, Stojadinovic et al (2008) ASWC 2008

  18. Dressings: What Do We Know? One Size DOESN’T Fit All… • Selection is based on- • Wound requirements (i.e. moisture content) • Patient requirements (usage frequency/ cost) • Think Property-- not Product (or Brand Name!) Question: What is Our Goal? Answer: A Clean, Moist Wound Bed

  19. Foot Infection • What do we KNOW? • Recognition is Critical, but challenging… Critical Colonization? Contaminated? • Pain • Pus Colonized? • Erythema • Systemic Illness

  20. Diabetic Foot Infections What We Don’tKnow- • Diagnosis: NO definitive consensus- • Only 3 studies suitable for review • Deep tissue cultures most likely of benefit • Antibiotic selection: NO definitive consensus- • Only 23 studies identified (5 with oral agents) • Evidence too weak for specific drug recommendations or duration of therapy O’Meara et al. Diabetic Med 2006;23:341 Nelson et al. Diabetic Med 2006;23:348

  21. Hyperbaric Oxygen Therapy (HBO)

  22. 1. Mechanical 2. Oxygen delivery 3. Antimicrobial effect 4. Poison Antidote Alters the size of gas bubbles Supplies O2 to ischemic tissues/ cell signaler Bacteriostatic/ cidal Reverse effects of CO and Cyanidethrough gas exchange How does HBO Work?

  23. HBO Accelerate the rate of healing Reduce amputation rates Increase the number of wounds that are completely healed at long term follow-up HBO therapy is an adjuvant treatment and can be used at any stage of the wound care process. Faglia E, et al. Diabetes Care. 1996;19:1338-43.

  24. Should Endovascular Procedures Remain in the Hospital or Move to Outpatient Centers?

  25. Patient Safety • Multiple papers have shown safety in outpatient centers • Gradinskak JL, et al. Risks of Outpatient Angiography and Interventional Procedures: A Prospective Study. AJR 2004;183:377-381. • Zayad HA, et al. Day case angioplasty in diabetic patients with critical ischemia. Int Angiol. 2008 Jun; 27 ( 3): 232-238. • Huang DY, et al. Day-case diagnostic and Interventional Peripheral Angiography: 10 year experience in a radiology specialist nurse led unit. Br J Radiol. 2008 Jul 81 (967): 537-544. • Lewis DR, et al. Vascular Surgical Intervention for complications of cardiovascular radiology: 13 years experience in a single center. Ann R Coll Surg Engl. 1999 Jan. 81(1);23-6 • Kruse JR, et al. Safety of short stay observation after peripheral vascular intervention. J Vasc Inter Radiol. 2000 Jan; 11(1);45-9.

  26. Recipe for Outpatient Safety • Standard quality controls in place • Only procedures and technologies proven to be safe in the outpatient setting should be performed (ie diagnostic arteriograhy, venography, venous ablation, balloon angioplasty, atherectomy vena caval filters, filter removal, and stenting) • Procedures to prevent wrong side interventions, incorrect medication administration, and other safety precautions, standard in hospital environments must be followed. • Timely production of outpatient reports and hard copy of the images is encouraged.

  27. Recipe for Outpatient Safety Cont’d • Standard quality controls in place • Tracking of complications and other quality parameters such as fluoro time and contrast amount should be followed. • A plan to deal with emergencies; including on site trained ACLS providers and transport to a higher level of care. • Strict Inventory review on a scheduled basis • Thought in patient selection

  28. Patient Satisfaction • On time appointments • Convenient locations • Shorter wait times • Easier scheduling • On-site parking • Less intimidating surroundings • Less cost (co-pay)

  29. Physician Satisfaction • Working in a familiar facility close to office • Higher reimbursement • Direct control over: • Safety • Quality • Personnel • Equipment • Cost

  30. Criticisms • Minimal patient safeguards • Outdated/inefficient technology • Ill-prepared/insufficient staff • Reduces inpatient angiographic volume and experience • Negatively impact nearby hospitals finances • Profit motive for physicians may result in unnecessary testing and procedures • May result in “cherry picking” less complicated cases and only those who are insured.

  31. Trends in Endovascular and Bypass Surgery Goodney et al; J Vasc Surg 2009: 50;54-60.

  32. Comparison of the Odds of Undergoing Lower Limb Procedures Between Two Groups of Patients Westchester Square Medical Center Bronx, New York Balar, N. Endovascular Today Aug 2011

  33. Rate of Lower-Extremity Amputations in Medicare Patients per US Census Bureau JACC Vol.60, No 21, 2012

  34. Geographic Variation in Lower-Extremity Amputation Compared with National Average JACC Vol.60, No 21, 2012

  35. Thank you!

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