Endovascular Essentials Symposium Highlights PAD, Ulcers, and Medical Management

ISET 2019 began with an important symposium on the essentials of endovascular therapy. Moderator Ripal Gandhi, MD, explained that the session was created in collaboration with the Society of Vascular Medicine, and he then introduced the first speaker, John Bartholomew, MD, who spoke on the scope of the problem regarding systemic cardiovascular risks in PAD patients.

“PAD is common but your patient has never heard of it,” said Dr. Bartholomew. He pointed to studies showing that although approximately 9 million people in the US have PAD, only 26% of individuals queried had ever heard of it.

Management of PAD, he said, should take a three-pronged approach that includes prevention of myocardial infarction, stroke, and death; improvement in function and quality of life; and preventative measures to protect the feet and guard against amputation. Smoking cessation is key to improving patients’ survival rates. “Guidelines suggest that patients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit,” he said.

Joshua Beckman, MD, took the podium next to discuss medical management of patients following intervention and claudicants without intervention. He began with what he described as his most important point. “Everyone in this room who sees patients with PAD and does interventions should know that everyone else who takes care of these patients considers you the expert in PAD.” Patient care regarding medical therapies and referrals for tests thus rests in the hands of the physicians in the audience. “If you don’t do it, nobody else will,” he said.

Dr. Beckman described the role of guideline-based care and recommendations to reduce cardiovascular events, including statins, smoking cessation, antiplatelet therapy, ACE inhibitors, and supervised exercise. Supervised exercise is now covered by CMS, he noted. Additionally, he highlighted CHARISMA as a negative trial and said that data do not support giving aspirin and clopidogrel to PAD patients.

The session continued with a presentation by Raghu Kolluri, MD, who covered differential diagnosis of lower extremity ulcers. “It is important for us as interventionalists to understand the etiologies and treat the patients properly. From the door, if you see a leg wound, 90% of times you’ll be fine if you understand the common etiologies – venous, diabetic, and arterial.”

During his talk, Dr. Kolluri presented patient cases that illustrated various etiologies. The physical examination and patient history are important, he emphasized, as not all cases are PAD. As an example, he described a case where the causation was the explosion of a methamphetamine lab. Another case was a sickle cell ulcer, which looks just like venous ulcerations. “If there is an atypical location, question whether it’s vascular or not,” he said.

Next, Richard Neville, MD, stepped in for Vickie Driver, DPM, MS, to present her slides on the basics of wound care. In addition to vascular specialists/surgeons, an array of specialists care for patients’ wounds. “Wound care is a team sport,” Dr. Neville said. Coordination with the care team and timely selection of interventions is key, he noted.

Dr. Neville also covered the importance of debridement rather than antibiotics alone in preventing infection. He mentioned a mentor who told him, “Debride, debride, debride, and when you think you’re done, debride some more.” The heel in particular is an important place to be aggressive in debridement.

Wound care is a fruitful area of research, Dr. Neville said. “If you do get involved in this sector and are interested, there are certainly opportunities to advance the field.”

Following Dr. Neville, William A. Gray, MD, spoke about medical management of carotid artery disease. He said that he thinks carotid disease should be treated with medicine because, in the big picture, carotid intervention in the past few decades has dropped significantly. “Why is that happening? Probably because, broadly speaking, modern medical therapy has been effective,” he said.

During his talk, he covered data from the CREST and NASCET trials and treatment of symptomatic vs asymptomatic patients. “The best data available support that the judicious, expert, selective use of these therapies in a complimentary fashion which can result in overall improved patient outcomes, if done effectively, should make both procedures (CEA and CAS) safer,” said Dr. Gray.

Parag Patel, MD, continued the morning session with his presentation on evaluation of patients with acute arterial ischemia (ALI). Patients with ALI have a sudden decrease in limb perfusion that threatens the viability of the limb. “Our ability to readily and promptly diagnose these patients to begin correct therapy is critical,” commented Dr. Patel.

Dr. Patel discussed the differences between acute arterial embolism, which generally appears in a relatively healthy arterial tree, and acute arterial thrombosis, which typically appears in a previously diseased arterial tree. He also reviewed the clinical features of acute embolism versus ischemia. “Generally, the acute is a sudden onset of symptoms,” he said.

He covered factors such as collaterals, obstruction, and duration that determine the severity of acute ischemia, and he reviewed the mnemonic the 5 Ps (Pain, Pulseless, Pallor, Paresthesia, and Paralysis).

Ian DelConde, MD, gave the final talk before the break, covering the evaluation and diagnosis of the swollen leg. He explained that the starling forces in capillaries are the basic principle that determines the net flow of fluid from inside the capillary to the outside.

He reviewed the 2 types of leg edema—venous edema and lymphedema—and he cautioned the audience not to confuse leg edema with lipedema, which is fat distribution rather than edema. He emphasized that a systematic approach is necessary for treating edema and that distinguishing between systemic versus local causes is important. “Understanding the pathophysiology of the patient’s edema is key to a successful treatment,” he said.

--Lauren LeBano