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Have been treating this wound for approx 1 year. Pt is Diabetic last A1c 5.6, PAD, Kidney disease, has history of multiple amputations with infections, including LLE BKA several years ago. Pt has severe kidney disease followed by nephrologist, used to be dialyzed however no longer on dialysis. Hx of Afib, stable followed by Cardiologist. Pt also followed by Vascular and has had angioplasty in the past. Vascular concerned about kidney function and says there is nothing more he can do. I have been performing debridements, used Collagenase, and compression wraps. At times when healthy granulation appears, I have used various skin substitutes including Puraply, Epifix and other amniotic products. The human derived seem to perform a little better. I also performed STSG several months ago when granulation tissue was healthy. I am now at a point where wound size is not decreasing and drainage is moderate. Pt has also recently completed course of PO abx.

Wound origin: 3+ years ago started as a blister which became infected, had skin graft placed and initially healed.
Jan 8, 2021 by Adam K Brown, DPM
2 replies
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA
Hi--thank you for the inquiry, I do have a few additional questions:
Is he ambulatory?
What type of compression are you applying and with what frequency?
Nutritional status?
Does he have pneumatic compression devices at home?
Have you considered biopsy?
I see he has received vascular (I assume arterial) intervention, but has he had venous mapping and been assessed for any potential venous procedures or intervention?
Jan 8, 2021
Elaine Horibe Song
MD, PhD, MBA
Great questions that Samantha posted. Dr Worth and I exchanged some notes and are curious about those too.

Given the information provided, it's possible that the etiology is mixed (arterial and venous, at least), with delayed healing due to multiple comorbidities including diabetes, severe kidney disease, and maybe other comorbidities that usually go along with these conditions.

A couple of questions in addition to Sam's: 
- Are PAD and other risk factors being medically managed? That is, is the patient receiving adequate antithrombotic therapy, lipid lowering therapy, hypertension management? Smoking cessation program if a smoker (first hand or second hand)? 
- Has vascular considered other alternatives to improve blood flow other than angioplasty? 
Jan 8, 2021
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