Imaging Studies

See the list below:

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 with conventional angiography or surgery.^[11]Owen and coworkers found that MRA detected all runoff vessels when compared with conventional angiography and, in fact, was more sensitive than conventional arteriography for visualizing both runoff vessels and arterial stenosis.^[12]
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 with approximately 40% for descending venography. Neglen and Raju suggest that combining duplex scanning with air plethysmography helps to differentiate severe venous disease from mild venous disease.^[13]
- 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

See the list below:

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 to 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.

Treatment & Management

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Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ. July 2007. 335:7610. [QxMD MEDLINE Link].
O'Brien JF, Grace PA, Perry IJ, et al. Prevalence and aetiology of leg ulcers in Ireland. Ir J Med Sci. 2000 Apr-Jun. 169(2):110-2. [QxMD MEDLINE Link].
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Lane RJ, Cuzzilla ML, Harris RA, Phillips MN. Popliteal vein compression syndrome: obesity, venous disease and the popliteal connection. Phlebology. 2009 Oct. 24(5):201-7. [QxMD MEDLINE Link].
Rasmussen JC, Aldrich MB, Tan IC, et al. Lymphatic transport in patients with chronic venous insufficiency and venous leg ulcers following sequential pneumatic compression. J Vasc Surg Venous Lymphat Disord. 2016 Jan. 4 (1):9-17. [QxMD MEDLINE Link].
Polak MW, Siudut J, Plens K, Undas A. Prothrombotic clot properties can predict venous ulcers in patients following deep vein thrombosis: a cohort study. J Thromb Thrombolysis. 2019 Nov. 48 (4):603-9. [QxMD MEDLINE Link]. [Full Text].
Yucel EK, Dumoulin CL, Waltman AC. MR angiography of lower-extremity arterial disease: preliminary experience. J Magn Reson Imaging. 1992 May-Jun. 2(3):303-9. [QxMD MEDLINE Link].
Owen RS, Carpenter JP, Baum RA, et al. Magnetic resonance imaging of angiographically occult runoff vessels in peripheral arterial occlusive disease. N Engl J Med. 1992 Jun 11. 326(24):1577-81. [QxMD MEDLINE Link].
Neglén P, Raju S. A rational approach to detection of significant reflux with duplex Doppler scanning and air plethysmography. J Vasc Surg. 1993 Mar. 17(3):590-5. [QxMD MEDLINE Link].
Ashby RL, Gabe R, Ali S, et al. VenUS IV (Venous leg Ulcer Study IV) - compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model. Health Technol Assess. 2014 Sep. 18(57):1-293, v-vi. [QxMD MEDLINE Link].
Alvarez OM, Markowitz L, Parker R, Wendelken ME. Faster Healing and a Lower Rate of Recurrence of Venous Ulcers Treated With Intermittent Pneumatic Compression: Results of a Randomized Controlled Trial. Eplasty. 2020. 20:e6. [QxMD MEDLINE Link]. [Full Text].
Carvalho MR, Silveira IA, Oliveira BGRB. Treatment of venous ulcers with growth factors: systematic review and meta-analysis. Rev Bras Enferm. 2019 Jan-Feb. 72 (1):200-10. [QxMD MEDLINE Link]. [Full Text].
Edlich RF, Rogers W, Kasper G, et al. Studies in the management of the contaminated wound. I. Optimal time for closure of contaminated open wounds. II. Comparison of resistance to infection of open and closed wounds during healing. Am J Surg. 1969 Mar. 117(3):323-9. [QxMD MEDLINE Link].
Kavros SJ, Miller JL, Hanna SW. Treatment of ischemic wounds with noncontact, low-frequency ultrasound: the Mayo clinic experience, 2004-2006. Adv Skin Wound Care. 2007 Apr. 20(4):221-6. [QxMD MEDLINE Link].
Nelson EA, Mani R, Thomas K, Vowden K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev. 2011 Feb 16. 2:CD001899. [QxMD MEDLINE Link].
Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2012 Apr 18. 4:CD004123. [QxMD MEDLINE Link].
Kalani M, Apelqvist J, Blombäck M, et al. Effect of dalteparin on healing of chronic foot ulcers in diabetic patients with peripheral arterial occlusive disease: a prospective, randomized, double-blind, placebo-controlled study. Diabetes Care. 2003 Sep. 26(9):2575-80. [QxMD MEDLINE Link].
Cesarone MR, Belcaro G, Rohdewald P, et al. Comparison of Pycnogenol and Daflon in treating chronic venous insufficiency: a prospective, controlled study. Clin Appl Thromb Hemost. 2006 Apr. 12(2):205-12. [QxMD MEDLINE Link].
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Media Gallery

Vascular ulcers. Arterial ulcer with characteristic features.
Vascular ulcers. Venous ulcer with characteristic features.

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Author

Allen Gabriel, MD, FACS Professor, Department of Plastic Surgery, Loma Linda University School of Medicine

Allen Gabriel, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, 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 E Paletta, MD, FACS Clinical Professor of Surgery and Instructor of Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth; Clinical Professor of Surgery and Instructor in Surgery, Rwanda Human Resources for Health, Rwanda Ministry of Health and Clinton Health Access Initiative

Christian E Paletta, MD, FACS is a member of the following medical societies: American Society of Plastic Surgeons, Plastic Surgery Research Council, American Council of Academic Plastic Surgeons, American College of Surgeons, American 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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

Vascular Ulcers Workup

Imaging Studies

Other Tests

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