Vascular Ulcers Workup
- Author: Allen Gabriel, MD, FACS; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...
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- 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. 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.
- 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.
- 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.
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- If an ulcer is recurring, etiology is unclear, and all invasive and noninvasive studies have been preformed, a biopsy is essential to establish a diagnosis and further understand the etiology of the disease. As always, management of chronic wounds can be improved by understanding the true etiology and therefore treating the underlying problem.
- 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.
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