This week I saw a patient with terminal peripheral vascular disease (PVD). Seeing him reminded me of how often the severity of this disease is misunderstood. He had had amputation of the toes on his right foot due to gangrene. The toes on his left foot had early gangrenous changes, similar to what had happened on his right. Of course, amputation of the toes did not solve his problem, it just moved the gangrene up further. He now has a gangrenous wound at the amputation site. Also, he has a new gangrenous round ulcer on his lateral foot. This came from tape which had been used to fasten a dressing to his foot.

The only thing to do for his feet is to do as little as possible. For his amputation site, which is odorous with the gangrene, raw honey is applied daily or every other day. This is topped with a loose absorbent pad (such as an ABD), and held in place with a stockinette. The left foot toes are painted with betadine two or three times a week and the foot is covered with a loose sock. I did talk with the man about possibly using maggot therapy to clean the gangrenous stump; I asked him to think about it.

Considerations for Treating Patients with Peripheral Vascular Disease

What is often not remembered or realized with PVD is that this is a systemic disease, starting visually at the toes, but involving the whole body. The skin of the feet and legs is tremendously fragile and easily bruised or torn. What is frightening to me is how often medical people—doctors and nurses—will wrap such a leg with gauze or ace wraps, and wrap tightly. The body is having trouble sending blood into the legs and feet and a tight wrap makes that even harder, and therefore actually worsens the problem. Also, often it is thought to raise the legs up when there is a wound, but with PVD, you actually want to put the legs down so gravity will help the blood flow.

With this often-overlooked and frequently misunderstood disease, it is important to remember several things: when in doubt, get an ankle-brachial index to show if there is circulation. If you find poor circulation, remember how delicate the system is — no adherent dressings, avoid debridement if possible, keep legs dependent, and avoid wrapping the legs.

Treatment Interventions for Peripheral Vascular Disease

Once you find poor circulation, look to see if revascularization is an option. PVD inevitably leads to gangrene of the toes and feet unless revascularization can be done soon enough. If done with endovascular surgery, it is an outpatient procedure. Bypass surgery using the saphenous vein is a larger inpatient surgery, leaving scars. If revascularization cannot be done, then gangrene will occur. This, in and of itself, is not fatal. Gangrene can be kept dry and monitored for pain and infection. Pain can be treated with morphine, oxycodone or methadone if severe. Infection can be treated with maggot therapy. Raw honey is often helpful with wound odor.

As always, try to be aware of and know about the situations you are dealing with so that you can make the right decisions about what action to take for your patient.

About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.