Vascular Assessment and Management of Non-Healing Lower Extremity Wounds

Initial Vascular Assessment

The American College of Cardiology recommends measuring resting ankle-brachial index (ABI) in both legs to establish baseline and confirm peripheral artery disease (PAD) diagnosis, with a strength of evidence of Class I 1, 2, 3
If ABI >1.40 (noncompressible arteries), the American College of Cardiology recommends immediately obtaining toe pressure/toe-brachial index (TBI) with waveforms, as ABI alone is unreliable in this setting, with a strength of evidence of Class I 1, 2
The American College of Cardiology suggests obtaining transcutaneous oxygen pressure (TcPO2) and/or skin perfusion pressure (SPP) measurements in a warm room to prevent arterial vasoconstriction, as these predict wound healing potential, with a strength of evidence of Class IIa 1, 2, 4

Toe pressure <30 mm Hg indicates severe ischemia and decreased likelihood of wound healing, according to the American College of Cardiology, with a strength of evidence of Class I 1, 2, 4
TcPO2 <30 mm Hg suggests inadequate perfusion for healing, as recommended by the American College of Cardiology, with a strength of evidence of Class IIa 1, 2, 4
SPP <30-40 mm Hg predicts poor wound healing, according to the American College of Cardiology, with a strength of evidence of Class IIa 1, 2, 4
TBI ≤0.70 confirms PAD diagnosis, as recommended by the American College of Cardiology, with a strength of evidence of Class I 1, 2, 4

The American College of Cardiology recommends obtaining duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) to define anatomic location and severity of arterial stenosis, with a strength of evidence of Class I 1, 2
These imaging modalities are Class I recommendations for determining revascularization strategy in chronic limb-threatening ischemia (CLTI), according to the American College of Cardiology 1, 2

The American College of Cardiology suggests systematically evaluating for non-vascular causes of wound failure if perfusion measures are normal or only mildly impaired, with a strength of evidence of Class IIa 1, 4

The American College of Cardiology recommends assessing glycemic control in diabetic patients, with a target HbA1c <7%, with a strength of evidence of Class I 7
The American College of Cardiology suggests documenting smoking status, as smoking profoundly impairs wound healing through vasoconstriction, with a strength of evidence of Class IIa 7
The American College of Cardiology recommends evaluating nutritional status, as malnutrition impairs healing, with a strength of evidence of Class IIa 5, 8

The American College of Cardiology recommends assessing for excessive or persistent pressure at wound sites, with a strength of evidence of Class IIa 5, 8
The American College of Cardiology suggests evaluating foot structure and gait abnormalities in diabetic patients, with a strength of evidence of Class IIa 8

The American College of Cardiology recommends systematically documenting wound dimensions, location, tissue type, exudate, wound edges, periwound skin, and presence/absence of pedal pulses, with a strength of evidence of Class I 5

The American College of Cardiology recommends never delaying vascular assessment in patients with non-healing wounds, as inadequate perfusion is the most common reversible cause of healing failure, with a strength of evidence of Class I 7, 6
The American College of Cardiology suggests never relying solely on ABI in patients with diabetes or calcified vessels (ABI >1.40), as falsely elevated readings miss critical ischemia, with a strength of evidence of Class IIa 1, 2, 6