eMedicine Specialties > Plastic Surgery > Wound Healing

Vascular Ulcers: Workup

Author: Allen Gabriel, MD, Director of Research, Department of Plastic Surgery, Loma Linda University School of Medicine
Coauthor(s): Matthew C Camp, MD, Resident Surgeon, Department of Plastic Surgery, Loma Linda University Medical Center; Christian Paletta, MD, FACS, Professor, Division Chief and Program Director, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine; Brandon Massey, MD, Staff Physician, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine
Contributor Information and Disclosures

Updated: Aug 19, 2008

Workup

Imaging Studies

  • When noninvasive tests reveal unacceptable pedal perfusion, perform imaging studies of the lower extremity to identify the level of obstruction and to evaluate the distal runoff.
    • Perform angiography when visualization of the vessels of the lower extremities is desired. A femoral runoff study is the study of choice. It reveals the filling of leg vessels down to the ankle. The plantar arch also may be visualized if the location of the wound is distal enough to warrant it. This study is invaluable to both the plastic surgeon when providing coverage and to the vascular surgeon if revascularization is also performed.
    • Magnetic resonance angiography (MRA) can also be useful when evaluating lower extremity disease. Yucel et al found that MRA was 94% accurate in evaluating lower extremity vessels when compared to conventional angiography or surgery.4 Owen and coworkers found that MRA detected all runoff vessels when compared to conventional angiography and, in fact, was more sensitive than conventional arteriography for visualizing both runoff vessels and arterial stenosis.5
  • Imaging tests for venous disease can also reveal important preoperative issues.
    • Doppler duplex scanning can detect venous reflux with a sensitivity greater than 75%, compared to approximately 40% for descending venography. Neglen and Raju suggest that combining duplex scanning with air plethysmography helps differentiate severe venous disease from mild venous disease.6
    • Ascending venography also may be considered to obtain detailed anatomic information. This study can reveal axial channel patency, perforator incompetence, obstruction, and the presence of deep venous thrombosis.

Other Tests

  • Assess the vascular supply to the site of ulceration so that the likelihood of satisfactory wound healing may be estimated. Several methods of determining the adequacy of the pedal circulation are available.
    • Ankle-brachial indices (ABIs) and toe digital pressures with pulse volume recordings can provide good clues to the perfusion of the foot. Findings are also predictive of wound healing, although they may be misleading in patients with diabetes and calcified noncompressible arteries. An ankle pressure greater than 55 mm Hg suggests adequate leg perfusion. Research suggests that venous ulcers require a higher ABI for healing than arterial ulcers. The diagnosis of critical limb ischemia is supported by either an ankle systolic pressure of 50 mm Hg or less or digital pressures less than 30 mm Hg.
    • Xenon-133 clearance to measure blood flow can help estimate the chance of wound healing. A rate of 2.6 mL/100 g is believed adequate for healing.
    • Transcutaneous oxygen tension may be measured; however, a wide discrepancy exists with the minimal level below which wound healing does not occur. Most agree that a pressure of 30-35 mm Hg is sufficient for healing of more than 90% of wounds.

More on Vascular Ulcers

Overview: Vascular Ulcers
Workup: Vascular Ulcers
Treatment: Vascular Ulcers
Follow-up: Vascular Ulcers
Multimedia: Vascular Ulcers
References
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References

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Further Reading

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Keywords

vascular disease, vascular diseases, vascular ulcer, leg ulcer, vascular legs, venous ulcer, diabetic ulcer, ischemic ulcer, vascular peripheral, foot ulcer, neurotrophic ulcer, vein ulcer, vascular surgery, arterial vascular, vascular diabetes, ulcer treatment, peripheral vascular disease, nonhealing ulcer, chronic ulcer, non-healing ulcer, hypertension, atherosclerosis, vasculitides, Buerger disease, thromboangiitis obliterans, Takayasu disease, Takayasu arteritis, leg ulceration, venous ulceration, ischemic ulceration, vein ulceration, chronic ulceration, arterial ulcer, neurotrophic ulcer, venous ulcer, stasis ulcer

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Contributor Information and Disclosures

Author

Allen Gabriel, MD, Director of Research, Department of Plastic Surgery, Loma Linda University School of Medicine
Allen Gabriel, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, and California Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Matthew C Camp, MD, Resident Surgeon, Department of Plastic Surgery, Loma Linda University Medical Center
Disclosure: Nothing to disclose.

Christian Paletta, MD, FACS, Professor, Division Chief and Program Director, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine
Christian Paletta, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Brandon Massey, MD, Staff Physician, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Albert E Cram, MD, FACS, Professor Emeritus, Departments of Surgery, Otolaryngology Head & Neck Surgery and Orthopedic Surgery, University of Iowa College of Medicine; Consulting Staff, Iowa City Plastic Surgery
Albert E Cram, MD, FACS is a member of the following medical societies: American Association of Tissue Banks, American Burn Association, American College of Surgeons, American Heart Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Wayne Stadelmann, MD, Stadelmann Plastic Surgery, PC
Wayne Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Subhas Gupta, MD, PhD, CM, FRCS(C), FACS, Professor of Surgery, Chair, Department of Plastic Surgery, Director of Plastic Surgery Residency, Director of Comprehensive Wound Service, Department of Plastic Surgery, Loma Linda University School of Medicine
Subhas Gupta, MD, PhD, CM, FRCS(C), FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Phlebology, American College of Surgeons, American Medical Association, American Medical Informatics Association, American Society of Plastic Surgeons, California Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, College of Physicians and Surgeons of Ontario, Plastic Surgery Research Council, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada, and Wound Healing Society
Disclosure: Nothing to disclose.

 
 
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