The Appropriate Tests for Vascular Assessments

In this video, Matt Regulski, DPM, FFPM RCPS (Glasgow), ABMSP, discusses the appropriate tests when assessing vascular health in patients with chronic ulceration.

Transcription

Hello. My name is Dr. Matthew Regulski. I'm the medical director for the Wound Institute of Ocean County, New Jersey, and also a senior partner at Ocean County Foot and Ankle Surgical Associates, Toms River, New Jersey. I just wanted to talk for a few minutes about vascular assessment and vascular testing in patients that have chronic lower extremity ulcerations. Now, whether it be any type of lower extremity ulceration, you need to have a vascular study done. Palpation of pulses don't include or exclude the diagnosis of vascular disease. You need a quantifying examination, ABI, and PBRs, with toe pressure or toe brachial indices is preferred. And the reason we go all the way to the toes is that it's a much better predictor of blood flow and wound healing. Because as you know that arteries in the ankle become calcified and you can get falsely elevated pressure readings.

In the toes, they usually lack an adventitious lining, so they don't get as calcified and we can get better measurements of toe pressures. And you really want to be anywhere above 30 to 40 preferably 40 in the toes is a better predictor of healing, but we always want to get to the toes. Don't stop at the ankle. And the reason we do that is that obviously as you're aware that all chronic wounds are hypoxic and we don't have proper oxygen intention, you don't have collagen synthesis, angiogenesis, resistance to infection, or epithelialization. I've seen a multitude of patients that have come for the second opinion consults, things of that nature, who haven't had a vascular study since they had their wound. Or if they were exhibiting types of pain and cramping, things where they have to get up at night and walk it off as could be vascular disease. Obviously, if patients have ischemic rest pain or claudication pain, claudication pain is when they get calf pain when walking, where they have to sit down and allow that to relieve themselves for a specific period of time.

So it is very important that we have a vascular assessment for all chronic ulcerations, whether you see them, this is the first encounter event with the patient, or if they had a healed wound and a wound has recurred somewhere on the body or somewhere in that general vicinity of the previous ulceration, or if the patient comes to you and starts talking about cramping pain, or they're having pains in the calves or pains in the legs, they're hanging their legs over the side of the bed at night, things of that nature. Then we need to have vascular testing. Diabetes and vascular disease go hand in hand. Diabetes makes plaque. Arteries respond the same way in your toe as they do in your brain. Okay? So we need to have a vascular assessment in our diabetic patients. They're at much risk for heart attack and stroke, about two and a half times greater risk for heart attack and stroke than the non-diabetic patient.

So it's also very important that every diabetic has a cardiologist since 80 to 90% of diabetics will die from heart attack and stroke. And you'd be surprised how many diabetics out there do not have or didn't know that they need to see a cardiologist. And always remember that diabetes affects every system in the body, so they need to have a multitude of doctors. They need ophthalmology, they need cardiology. They may need a GI guy because of gastroparesis caused by diabetic autonomic neuropathy.

They need the podiatrist, of course. they need a vascular specialist, whether it's an interventional cardiologist, interventional radiologist, or vascular surgeon. They may need also a pedorthist or an orthopedist, possibly a nutritionist, endocrinologist, internist, orthopedist, plastic surgeon, and nephrology as well. So it is a total team effort. There's not one doctor that can treat all those problems. But you, as the wound healing specialist, if somebody comes to you with a chronic non-healing wound, whether it's recurrent or an initial encounter, please make sure that we get a vascular study so we can assess their circulation and any problems with that circulation, any questions in your mind, whether they have stenosis, which is a narrowing, or they have a monophasic flow.

When you see on a PVR, monophasic flow essentially means they're a lead pipe all the way down, they're calcified, but if they have chronic wounds, then there is nothing wrong with having a referral to your vascular specialist to get his or her opinion on that subject. And if there's anything that they can do to increase more inline flow will only help your patient. So please remember chronic wounds are hypoxic. We need to have vascular studies, especially in the diabetic population and also in the venous leg ulcer patients, not only do you do an arterial study because 15% of that population will have significant arterial disease, but you need a venous reflux study. In venous reflux studies, you really need a good tech that is trained in doing that, because you're just not looking for a clot. You're looking at the superficial, the perforator system, and the deep venous system.

So you have to have somebody that is skilled because as venous ulcers go if they have reflux, that needs to be fixed. Because if you don't, your healing rate is abysmal, maybe 20% and you have an 88% recurrence rate within three months. So it's very important that we stop that venous backflow, that venous hypertension, which feeds into that ulceration. And even when you're treating venous ulcers, since 93% are open longer than a year, 7% are open longer than five years. It's very important too, that you constantly assess that venous circulation. They may need to have a periodic test. If the healing is slow, even though they might have had an ablation two, or three months ago, I've seen patients then would have significant perforator disease and sclerotherapy, and those things of the nature where they can inject these perforating veins can go a long way and help heal your patients. So remember, chronic wounds are hypoxic. Please get a vascular study.