Chronic wounds or wounds that are “hard-to-heal” are a significant healthcare burden, affecting millions of individuals worldwide. Peripheral vascular disease (PVD) is a common underlying condition that plays a crucial role in the development and management of hard-to-heal wounds. In this blog post, we will delve into the intricacies of PVD and its implications for wound care, drawing upon evidence from reputable sources like WoundReference.com, The Journal of Wound Care, and The Journal of Vascular Surgery.
1. Peripheral Vascular Disease: An Overview
Peripheral vascular disease refers to a group of disorders characterized by reduced blood flow to the extremities, primarily the legs. It is commonly caused by atherosclerosis, a condition where the arteries become narrowed due to the buildup of plaque. PVD can manifest as various conditions, including peripheral artery disease (PAD), chronic venous insufficiency (CVI), and peripheral lymphatic disease (PLD). PAD is the most prevalent form of PVD and is often associated with wounds that are hard to heal. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. While this blog article will focus on PAD and the serious risks this poses to our patients with hard-to-heal wounds, future articles will address some of the challenges we see in patients with CVI and PLD.
2.Link between PAD and Hard-to-Heal Wounds
PAD significantly affects wound healing processes due to the compromised blood flow to the affected area. The reduced oxygen and nutrient supply, coupled with impaired waste removal, impede the normal wound healing cascade. Several studies have elucidated the correlation between PAD and chronic wounds, underscoring the need for tailored interventions.
According to a study published in The Journal of Wound Care, PAD is present in up to 70% of patients with chronic leg ulcers. The researchers found that the severity of PAD, measured using ankle-brachial index (ABI), was directly proportional to the size and healing time of the ulcers. These findings highlight the critical role of PAD in chronic wound development and emphasize the necessity of addressing vascular insufficiency in wound care management.
3. Diagnostic Evaluation of PAD
Accurate diagnosis of PAD is crucial for effective wound care management. Several diagnostic tests can help assess the extent of vascular impairment in patients with chronic wounds. The ankle-brachial index (ABI) is a simple and widely used test that compares the blood pressure in the ankle to that in the arm. A low ABI indicates the presence of PAD.
A study published in The Journal of Vascular Surgery highlighted the diagnostic accuracy of ABI in assessing PAD-related wounds. The researchers found that an ABI of less than 0.5 had a high specificity and positive predictive value for identifying PAD-related wounds. This emphasizes the importance of ABI in diagnosing PAD and guiding appropriate wound care interventions. At Athena Specialty Group we work closely with our healthcare partners in the community to bring these diagnostic tests to the patient in their home setting whenever possible.
Given that many of our patients with PAD are also diabetic, it is important that our wound care providers understand the challenges that come with assessing PAD in our diabetic population. Diabetes can lead to calcification of the blood vessels in the extremities which can make tests like the ABI inaccurate for this patient population. At Athena Specialty Group, our wound care providers are trained to perform a thorough systems review and physical evaluation of our patients in order to identify potential risk factors for PAD and to perform additional bedside assessments of vascular insufficiency. We also partner with the vascular surgeons and interventionists in each of our territories to be able to provide potentially limb or life-saving interventions to our patients in a timely manner.
4.Wound Management Strategies for PAD-Related Wounds
Effective wound management for PAD-related wounds necessitates a multidisciplinary approach. Addressing the underlying vascular insufficiency, when possible, is crucial for promoting healing and preventing complications. The following strategies are commonly employed:
a. Revascularization: In cases where arterial insufficiency is significant, revascularization procedures such as angioplasty or bypass surgery may be required to restore blood flow to the affected area. These interventions aim to improve tissue oxygenation and promote wound healing.
b.Wound Dressings: Selecting appropriate wound dressings plays a vital role in promoting healing and preventing infections. Alginate dressings, foam dressings, and hydrocolloids are commonly used for PAD-related wounds, as they provide a moist wound environment while managing exudate effectively. Our wound care providers at Athena Specialty Group are trained to carefully assess the wound at each of their visits to determine the treatment plan that will optimize the patient’s chances for wound healing.
c.Hyperbaric Oxygen Therapy (HBOT): Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized environment. This extra oxygen helps fight bacteria. It also triggers the release of substances called growth factors and stem cells, which promote healing. A systematic review and meta-analysis of adjunctive therapies in diabetic foot ulcers published in the Journal of Vascular Surgery found evidence supporting the use of HBOT as an adjunctive therapy to enhance diabetic foot ulcer healing and potentially prevent amputation. While HBOT cannot be offered in the home, the wound care providers at Athena Specialty Group are trained to identify patients who would benefit from HBOT and will work with the HBOT providers in our communities to help our patients obtain this adjunctive therapy when indicated.
d.Innovation: In the ever-growing world of wound care there are always new technologies evolving to help our patients with hard-to-heal wounds. Athena Specialty Group partners with the healthcare and technology industries to study the efficacy of some of these new treatment options. Some of the new technologies Athena Specialty Group is partnering to study include a mobile platelet-rich-plasma treatment and wearable oxygen therapy for wound healing. Future blog articles will address more about Athena Specialty Group’s role in wound care innovation.
Peripheral vascular disease, particularly peripheral artery disease (PAD), significantly impacts the development and management of hard-to-heal wounds. Understanding the link between PAD and hard-to-heal wounds is crucial for healthcare professionals involved in wound care. Our wound care providers at Athena Specialty Group are trained to identify PAD as a potential root cause of delayed healing in our patients with hard-to-heal wounds and will work with the vascular surgeons and interventionists in our territories to get our patients the limb and life-saving interventions and therapies they need. Revascularization procedures along with indicated adjunctive therapies and the selection of appropriate wound dressings to promote a healing environment are all vital components of the healing process for our patients with hard-to-heal wounds. By adopting a comprehensive approach that addresses both the wound and the underlying vascular pathology, our wound care providers at Athena Specialty Group can optimize outcomes for patients with PAD-related wounds.
- Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;CD002303. (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002303.pub3/full)
- Moffatt C. Using compression therapy to manage venous leg ulcers. J Wound Care. 2016;25(Sup9a):S4-S11. (https://www.magonlinelibrary.com/doi/full/10.12968/jowc.2016.25.Sup9a.S4)
- Elraiyah T, et al. A systematic review and meta-analysis of adjunctive therapies in diabetic foot ulcers. J Vasc Surg. 2016;63(2S):46S-48S.e2.
- Lanting SM, Twigg SM, Johnson NA, Baker MK, Caterson ID, Chuter VH. Non-invasive lower limb small arterial measures co-segregate strongly with foot complications in people with diabetes. J Diabetes Complications. 2017 Mar;31(3):589-593.
- Barnes JA, et al. Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease. Arteriosclerosis, Thrombosis, and Vascular Biology. Volume 40, Issue 8, August 2020; Pages 1808-1817.