In a country where more than 9% of adults have diabetes, Alexander Reyzelman, DPM, discusses the implications for those who also have peripheral vascular disease. He describes how to efficiently distinguish PAD – an underdiagnosed, undertreated problem – from other conditions; explains how to classify claudication; and clarifies when intervention is needed. Finally, hear why the UCSF Center for Limb Preservation focuses on speedy delivery of care that integrates podiatry and vascular surgery.
My name is Alex Reyes lumen. I'm co director of UCSF's Center for limb preservation And the professor of the California School of Podiatric Medicine. My passion in in the 20 plus years of my career has been taking care of patients with P A. D. And D. And the complications of diabetes, lower extremity complications of diabetes. This is a very large topic, there's a lot to talk about. So Um I had to condense into the next 25-30 minutes and please go ahead and ask questions towards the end. Would love to interact. This is a very significant problem that I think majority of providers don't really realize how severe this is And I hope to shed some light on this problem in the next 20 minutes or so. So when we look at P A. D, what we call a cardiovascular epidemic, there are significant facts that we just need to know about the epidemiology BA. D. effects afflicts 8-12 million Americans and carries an atherosclerosis risk, similar to symptomatic coronary disease. It's increasing as a result of aging US population and smoking diabetes and a bunch of other factors and frequently is the first sign of cardiovascular disease. Studies have demonstrated that PhD is underdiagnosed and undertreated important implications for both life and limb. So somebody with ph D is 2 to 6 times fold increase for heart, for heart disease and stroke and it leads to severe disability or even limb loss. We know that in the United States there are more than 80,000 major amputations performed per year affecting 1.4 million Americans living with major limb loss just for lower extremity PhD are very evident And I'm going to go over some of these if you're less than 50 with diabetes and you have one additional risk factors such as smoking this lipid anemia, hypertension or hyper homocysteine anemia. You're at risk if you're aged between 50-69 and history of smoking or diabetes you're at risk for PhD. If you're over 70 years of old of age without any other comorbidities. You're at risk for PhD. People with leg symptoms with exertion suggestive of Claude, education or ischemic rest pain. Clearly a risk factors for P. A. D. Abnormal lower extremity pulse exam is an obvious one. And known atherosclerotic coronary coronary a renal artery disease places you at risk for PhD. I think it's important to understand that P. A. D. C. A. D. Uh carotid disease, renal disease, they're all the same disease. It's macro vascular disease. So if you're treating somebody with a history of carotid endarterectomy, somebody who's had an M. I. There's a should be a high index of suspicion for P. A. D. And vice versa. When we're seeing patients with ph. D. We have to be mindful that the same patient maybe having C. A. D. Or carrot a disease and we may be able to prevent mes and strokes. If we get these patients appropriate work up sooner. There are different methods of assessing our for arterial insufficiency or P. A. D. Um Many of these are what we employ in our clinics. You may know some of them ankle and toe pressures or A. B. I. This is a big screening tool that some of you may have done or maybe doing it. Now segmental Doppler pressures, post volume recordings. These are all non invasive arterial studies. We put them in this category. We also performed tissue perfusion tests with TCP 02 which is transplant, A. Gnaeus pulse oximetry. We have skin profusion pressure devices and hyper spectral tissue oxygenation devices to really assess non invasively whether somebody has material disease. And of course we have an atomic imaging such as ultrasound ct A. M. R. A. And then angiography. This is just a schematic of a typical A. B. I. Where we measure ankle pressure and systolic pressure in the arm and then the ankle. Over Break Hill is pressure. Is gives us the index and the normal index is really between 0.9 to 1.1. Anybody that falls below 0.9 by definition has P. A. D. The lower they are if it's 0.6 point five than the more severe P. A. D. Is. So if you're if you're performing these great if you're not you should refer these patients to a center that is able to do these tests. This is just an example of how we do it. It's a simple blood pressure cuff that's put around the ankle and then we use pulse oximeter to put around the distal tip of the toe and were able to get way forms. Hence we're able to get the pressure of of the ankle as well as the toe. This is an example of transportation es six symmetry. Uh This particular device is a very expensive device usually only used in the vascular surgery clinics or wound care centers. Now when we talk about P. A. D. I think the way to think about it is the P. A. D. Is a spectrum. It's not that one day patient wakes up with PhD patient develops P. D. In terms of their severity over many years. So they may come in with mild disease, then progress to moderate disease and eventually progress to severe disease. So we break down PhD in several categories. Number 1 50% of patients with ph D. Are asymptomatic. They're walking around without knowing that they have PhD. 30% of of PhD is a typical leg pain. So patients don't even know that it's related to ph D. But they have some form of pain in the leg. 20% of P A. D. Is classic intermittent communication which we'll talk about in just a second. And only 2 to 3% of P A. D. Is critical limb ischemia which is end stage P A. D. Which is the very severe form of P A. D. Which we'll talk about in a minute as well. History, physical exam, noninvasive physiologic studies established the diagnosis and majority of cases. But you have to have an index of suspicion. So what is intermittent qualification? Sometimes we get confused and we don't really know what that means. But in simple terms interment qualification is pain in the muscle, big muscle groups such as the buttock, thigh, musculature, or calves or even the arch of the foot, the intrinsic muscles of the foot. The intermittent communication by definition has to be painted in the muscle group during exercise or during activity. Most of these patients, they're not exercising, they're walking, they're having difficulty walking 12 or three blocks. What happens is the typical history is patient describes pain and their calves when they're walking and the pain is so severe that they have to stop and it's not truly a cramp, it's pain in the muscle that makes them stop once they stop they rest pain goes away because more blood flow comes back to the musculature, the pain goes away, they're able to walk. But what's interesting about instruments medication, it is repetitive, it's consistent meaning that if you have one block clarification, you will have it every single block you're not going to have a patient comes in and says, I'm gonna I walk one block today and I have pain but tomorrow or a week ago I walked 34 blocks and I didn't have pain that inconsistency is not intermittent communication, intermittent medication has to have same block pain every two blocks every three blocks every block. And it doesn't vary from one week to another. Usually the disease is the segment above where the muscle is. If the pain is in the calf, usually the arterial disease is going to be in the popular tibial artery segment above. If the disease is in the thigh, the the arterial, if the pain is in the thigh, arterial disease is going to be a segment above, probably in the iliad ephemeral area. Not all leg is pad. We have to have a differential diagnosis very calm to a spinal cord disease or spinal stenosis, mimic intermittent communication. The difference between spinal compression or narrowing of the spinal cord is that that disease is not consistent. It's not every block week to week or every two blocks a week to week. One day it's going to be three blocks one day the patient is going to be able to walk one block but it's not consistent. So that's a usual clinical way of differentiating peripheral neuropathy is another differential diagnosis. Osteoarthritis of the hip or knee, muscle spasms or cramps. And I have to spend just a second telling the cramps at night. Typically patients have cramps at night. That is not P. A. D. Okay, when you really have that true uh severe cramp in your muscle that many of us have experienced. That just happens haphazardly. That is not P. A. D. Ph. D. S paying in the muscle group during walking or exercise, restless leg syndrome is another differential. And sometimes venus disease. Um With varicose veins could mimic paddy or intermittent clarification. Now as we jump into chronic limb threatening ischemia. This is the end stage P. A. D. Intermittent communication is more moderate and chronicle chronic limb threatening ischemia is more severe. This is when we're having patients develop ischemic resting. This is where the patient will complain. I have to dangle my feet at night in order to get rid of the pain. So they wake up because of the pain because there's lack of blood flow coming to their feet. Now that ischemia that's created in the foot is causing pain. So what happens is these patients have to dangle their feet, allow gravity to overcome their conclusions and their arteries and that increased blood flow with gravity helps to overcome their pain. That is true. Ischemic rest pain and this is pre gangrenous stage. Also. Uh chronic limb threatening ischemia can come with tissue loss. So if you have a tow ulcer, a foot ulcer gangrene, all of these are end stage P A. D more severe compromise of circulation which carries with it a high risk of amputation. If not treated. So if somebody comes in with a typical ischemic ulcer or gangrene. These patients are at very high risk for below the knee or above the knee amputation. And also these patients are increased risk for cardiovascular morbidity and mortality. Okay how do we treat P. A. D. Um Typically if you're if you have a symptomatic disease it's risk factor management and surveillance. There's no role for prophylactic revascularization. And I think this is an important part. You some of you may have seen this where patients are getting stinted, they're getting angioplasty is performed yet. They don't really have any foot ulcers. They don't have gangrene. So it's more prophylactic. There is no prophylactic revascularization because it's a risky procedure. And many times we see patients who undergo prophylactic procedures and they burn bridges. They have problems with with um showering mbali down the leg which then causes some major issues. So we have to be very careful. Not all P. A de deserves intervention intermittent communication treatment is typically risk factor management, exercise and pharmacologic therapy. Exercise has shown evidence has shown that if you have the patient walk consistently every day with history of intermittent medication they're intermittent medication improves. So if they were to block Claude Akins they may become a three block logic in a four block Claude Akins. But that takes time. So it's consistent daily routine of pushing themselves and exercising the muscle that increases angiogenesis opens up collaterals and the pain tends to improve. Ah sometimes we do interventions with stenting or angioplasty. If intermittent communication becomes disabling and that's really the operative word here is disabling. What do we mean by disabling. Well let's say that you have a mail carrier who is not able to do his route of five blocks and he's able to walk only two blocks and he gets pain and is not able to finish their job where they would do his job adequately. That's disabling to that particular individual that may need to be intervened on. We may need to work this patient up and perform a balloon angioplasty, maybe a stent. However, if you have an eight year old with two blocks medication that doesn't walk much and is able to get to her supermarket. That's a block away. That's not really disabling for that individual. Hence, intervention may not be necessary. And as we move into critical ischemia, this is where we absolutely have to intervene without intervention. These patients will lose their legs worse yet they may develop cardiovascular problems such as AM I. And strokes. So effective revascularization is really important. Um, fast work up. Quick intervention is really important. And that's the only way that we can prevent amputation in this high risk part of PhD. Now, we'll move into diabetes, diabetes in it of itself is a major problem and I think it's important to understand the magnitude of diabetes in the United States. And I don't know how many of you know these statistics, but I think some of them are pretty staggering. More than 30 million patients with diabetes in the United States, which makes up about 9.4% of the us population Over 300 million worldwide. And this continues to increase. Nearly 70% of amputations in the United States are performed in patients with diabetes. Age adjusted risk for amputation is 28 fold higher. So if patients patients with diabetes at 28 times higher risk for developing an amputation, It is estimated there is a diabetic undergoing lower extremity amputation every 20-30 seconds around the globe. Diabetic foot ulcer is a strong predictor for limb loss And among patients with the diabetic foot. Also that heel up to 80% of them will have a recurrence within one year. One out of three diabetics older than age 50 have PhD and diabetics with P. I. D. Are at significantly increased risk for mortality and limb loss. It's a huge huge public health expenditure and growing rapidly. Here's a chart Of the number and percentage of US population with diagnosed diabetes. If you look from 1960 2 1997, it's been growing at a steady state. But then in 97 it has a significant spike From 1997 to 2015 has been a tremendous increase in diabetes and it continues to increase today. And what about in California? What's happening in our own backyard in California? This is a fair this is fairly recent data. Um That that was published two years ago. I think it's been two years ago now. Mhm. Greater than 15.5 million adults which make up about 55% of all Californians have prediabetes or diabetes Greater than 1/3 of adults of color prediabetes And in California, lower limb amputations has increased by greater than 31% between the years of 2010 and 2016. We can further divide. Break this down based on counties. And if you look at the richest county in the United States which is marin county Amputations has increased from by 32% between 2010 and 16 San Francisco County by 16%. Alameda County 7%. Santa Clara County by 19 And San Joaquin County a whopping 41%. And this is here in California. And as we go further out closer to central California it gets even worse. Now, how does this happen? Why do diabetic patients develop um ulcers and subsequent amputation. It's really the triad between neuropathy, vascular empathy and immune. Op Athena. And what this means is neuropathy is um is the loss of sensation that develops in patients with diabetes over many years Now, if you've had diabetes for 10 years or greater, your risk of having neuropathy is probably 50-75%. So first what happens is patients slowly lose sensation. They developed pins and needles burning eventually numbness and eventually their sensation in the foot goes away. And we call that loss of, I always tell my patients this is where they lose the gift of pain because pain is really the protective mechanism that we have. But these patients lose that gift and now they're walking around without feeling on the bottom of their feet. So if they step on a nail, if they develop a callus, if they wear a shoe that's a little bit too tight, they will not feel the blister, they will not feel the damage that's occurring to their skin. So now the calluses is becoming more of an issue. There's injury underneath the skin and then that tissue breaks open. If you add vascular disease on top of that, that makes it even more difficult for that wound to heal. And then we already know that patients with diabetes have a monopoly. The they have poor defense and poor ability to fight infections. So when you put them all together, that leads to a major problem which eventually leads to infection and subsequent amputation. Uh this is a stairway to amputation that was published maybe 5-10 years ago. And this is again an easy way to think about this. And how does, how do we get to amputation? We first have diabetes, diabetes leads to neuropathy neuropathy opens the door to the ulceration, which is the break in the skin ulceration gets infected. When you add vascular disease on top of that, that leads to the bad outcome of an amputation. Why is this important? Because the stairway we can intervene and mitigate certain risk factors, we we can't reverse diabetes, we can't reverse the neuropathy. But we can't we can prevent ulcers. We can't treat infections and we can we can catch vascular disease with proper intervention. Timely intervention. Probably my favorite slide to present to my non podiatry colleagues. Because if you look at, we talk about amputations, but we also should talk about mortality. And when we think about five year mortality rates, we typically talk about cancers, right? We know that cancer is is the is what everybody is afraid of. Why? Because of mortality? Because it's it's some of the cancers lead to significant mortality. But what about diabetes and the complications that occur in the foot. And what is what about P. A. D. How does that affect mortality rates? So if we look at breast cancer, five year mortality rate, you can see that it's fairly low. If you look at a diabetic foot ulcer, which is this bar the red bar right here diabetic having a foot ulcer Patient that you see with a foothold. There carries at least a 30% 5 year mortality rate which is much higher than breast cancer. And higher than colon cancer. Okay. And higher than usually higher than non hodgkin's lymphoma. If you have charcoal, which is a complication of diabetes where the arch collapses and the bones collapsed, mortality rate is pretty high. When you have a minor foot amputation such as missing a toe or part of the toe or part of the foot, The more five year mortality rate approaches 50%. If you have a patient with chronic limb threatening ischemia, Five year mortality rate is greater than 50%. And then if you have a patient with a below the knee amputation, five year mortality rate is very high as well. So the only cancers that have a higher five year mortality rate, the majority of the foot problems for PhD and diabetes really our lung cancer and pancreatic cancer. Why is this important? Because I think we need to switch the way that we think about this when a patient walks in with P. A. D. When the patient walks in with diabetic foot ulcer or shark o or part of the toe is missing. We need to think about these people as having cancer because only then will we have the same diligence and care and plugged them inappropriately otherwise, we don't really think about it that way. So I think it's really critical for us to think of patients with diabetes and lower extremity complications as though they have a very aggressive cancer. Why is this a problem for us? Well, number one, there's a low level of public and community and the awareness. We have poor classification and staging systems that complicate management and communication between providers. There are multiple providers in the care is extremely fragmented and delayed. And why is that? Well, sometimes patients go to a podiatrist. Sometimes patients go to a vascular surgeon. Sometimes patients go to an orthopedic surgeon. Sometimes they go to a primary care physician, endocrinologist, They're all over the place. Therefore the care is fragmented. There's no one center that can take care of this big problem, diagnostic and therapeutic approaches are highly variable and the quality measures are not standardized. So in order to be successful, what we need to do is have rapid recognition and treatment of these advanced stages in order to get clinical and success. What we usually say is time is tissue. The reason that a lot of these people lose their feet is because they delay their care or we don't pick them up soon enough. So when we see these patients, we need to jump on them right away. We need to be able to diagnose them. We need to be able to intervene appropriately. And the longer time goes by the more time that goes by, the more tissue we lose. We also realized that close follow open cereal assessment is very important for progress. Once you have had an ulster, as I mentioned earlier, Up to 80% will re ulcerated within one year. If you have P. A. D. And you've had an intervention, there's a high rate of re stenosis in these patients. So their surveillance becomes very important in order to combat this problem. We set up i centered UCSF about 12 years ago now, which we call center for limb preservation and diabetic foot. This was the first of its kind in the Bay Area because we provided the multidisciplinary care. We realized that in order to save limbs in order to make a dent, we have to combine expertise and we were the first center of its kind to combine vascular and podiatry and then use other services such as endocrinology, orthotics and prosthetics plastic surgery to help us treat these patients and get them what they need. So we established the center in 2011, our Senate treats patients with foot ulcers, peripheral arterial disease and those at risk for developing these conditions. We're dedicated to functional preservation of limb which means we're not just thinking of preserving the limb. Which we're thinking how do we keep these patients active? How do we make sure that they maintain ambulatory status? We have a highly uh in a close coordinated effort between outpatient and inpatient setting which we believe is very important. The same team that treats the patient and in patient side is the same team that follows these patients on how patients side. We have a 92% limb salvage rate. Um We take consoles 24 7. We typically see patients within a 48 hour period, depends on the urgency of the situation, urgency of the situation. And it's very important for us that we communicate to our referral sources and to our partners in the community the conditions that we typically treat. Our diabetic foot ulcers, shark, oh, feed pressure ulcers, venous ulcers, patients with burger's disease with Reynaud syndrome, peripheral neuropathy and of course any other vascular condition which could be aortic disease or carotid disease or dialysis access as well. One of the the best parts of our center is that we consider ourselves a one stop shop when a patient comes to see us, we're able to do everything. We're able to see the patient in a combined fashion. A vascular surgeon, a podiatrist sees this patient and we're able to do noninvasive arterial set of studies in the same setting. So we tend to assess the problem and then develop a treatment plan as a team. This is just a slide showing that we have different tools in our toolbox, um intervention for paddy has evolved over the years. All kinds of interesting tools and devices. They're all kinds of different balloons. Their drug coated balloons. There are all kinds of a threat to me devices. There are all kinds of different stents and of course we still do the mainstay for many of these patients is the open bypass procedure. This is a guide, an amputation risk and screening guide that we will provide to all of you because I think this is an easy um easy guy to look and see how, what kind of risk are the patient and and how fast should we refer this patient. So we developed this a couple of years ago and basically it works like this if you are a diabetic patient and you don't have any symptoms and you don't have any foot ulcers and you don't have neuropathy. You're a low risk for amputation. This is a patient that should be screened annually by either primary care or if the primary care wants to refer him to a podiatrist that would be acceptable if the patient now develops numbness, tingling, burning of their toes, which are signs of peripheral neuropathy. Now they have moderate risk of amputation. This is a patient that but for sure needs to be seen by a podiatrist at least once a year to assess for P. A. D. And for peripheral neuropathy and for risk for developing ulceration. And then if the diabetic patient develops ulcer has history of calluses that are bleeding, that have bleeding into them. If they have pain in their feet at night, if they have symptoms of intermittent communication or they have had ulcers in the past. This is a high risk patient for amputation. This is the type of patient that we want to see right away. This is where we would schedule that patient within a week or probably within a couple of days. And finally, patient with severe risk for amputation with an active ulcer spreading infection, cellulitis, gangrene, Foot and ankle swelling with or without pain. This is a rapid referral, this is the patient will probably get in within 24 hours by calling our referral center in this in this slide. What I'd like to show you is that how we think about our limb preservation program. Um and how we partner with our community are our base. Is this UCSF proper in SAn Francisco where we do complex procedures such as open bypass or or foot surgery. However, we have a lot of partners. We have B. O. P. C. Which is Berkeley outpatient clinic where we have vascular presence that we do noninvasive studies in Berkeley. We have ST mary's hospital in SAn Francisco where we have our podiatrist and vascular surgeons who are doing the same thing. We have an outpatient post and san mateo we have clinics in the North Bay in the East Bay with with we partner with community podiatrists who are then able to screen these patients who are then able to follow these patients because we're not able to follow all of these patients for their wound care needs on weekly basis. But we do have partners all over the Bay area where where they know how we function. They're able to communicate to us at all times and they're able to see these patients closer to their homes. So what happens when the patient sees us in for initial evaluation? They undergo a comprehensive pediatric and vascular evaluation at the same time, a complete foot exam, assessment of deformity assessment of the wound. We we figure out whether there's a probing to bone where the bone is exposed. We assess for neuropathy, we take foot x rays, we take pictures we we take we perform noninvasive arterial study and then we stage the limb. There is a staging classification called wifi wound infection, ischemia and foot infection. And this system basically is like a cancer staging system. We're able to look at the foot at the leg and assign a risk category from 1-4. Risk Category one is a very low risk for amputation. Risk category four carries approximately 40% risk of amputation within a year. So much like cancer staging. The higher the stage, the worse the prognosis the same thing with the wifi. The higher the stage. It basically tells us, tells us that this patient needs to be seen in a multidisciplinary fashion and this patient needs to have intervention sooner the better. In order to to save the limb post discharge patients are following up with the same team on an outpatient basis or they're following up with our community podiatry partners surveillance is key. These patients will always be plugged into 1, 3, 6 months appointments to assess for recurrence of paddy, assess for re stenosis. Um The need for offloading and shoes and orthotics is always there. So these patients are patients for life and I'll probably end with, we're talking a little bit about our research program. UCSF Center for limb preservation is one of seven centers that were that was recognized by NIH who is currently doing a major major study on diabetic foot ulceration preventions and this is a consortium of seven different academic centers across the country and we're one of them. So we're always looking for patients to um put in our research programs. Our team is composed of vascular surgeons, podiatrists, four nurse practitioners and a patient care coordinator who is um Joanna Delong. She's always available. Will will pass around her cell number and she's always ready to answer. The phone calls are phone numbers. Mike Conte is my partner who is the chief of vascular at UCSF and myself will make the phone, our phone number is available. We're really easily accessible. We're happy to take your call or text or pictures and say what would you do with this patient? We're happy for curbside consults. We're very accessible because we want to be able to decrease the number of amputations and that's really the key for our center are foot care partners. We have locations throughout the bay area including sacramento, anywhere from san Francisco, South Bay, East Bay peninsula, North Bay. All of these centers are available to senior patients to screen your patients and to be helpful in any way and this is our team and without the team this does and work. It's all about team effort. No single specialty can help help decrease amputation. It takes really a team. So with that I will end and happy to answer any and all of your questions.