Palpable Distal Pulses Ensure Optimal Wound Healing of Large Ulcer Areas by Secondary Intention

Wound healing of ulcers with large areas can be a challenging task requiring secondary measures such as wound dressings, debridement on a regular basis, application of negative pressure therapy and even full- or partial thickness skin grafting.^1-3 Yet, complete restoration of distal perfusion manifested with restoration of palpable pulses over the posterior tibial artery or the dorsalis pedis artery can support and provide complete healing of large areas especially when other means are expensive, unavailable or restrict full return to daily activities. This principle is applied even in extremely large wound areas, such as those resulting after fasciotomies (Figure 1) or open amputations of the digits and metatarsals following successful revascularization (Figure 2).

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Figure 1.

A 56-year-old Male patient was admitted with acute ischemia due to thrombosis of popliteal aneurysm. The successful bypass surgery restored pulpable pulses distally but was followed with compartment syndrome necessitating extended fasciotomy of the anterior tibial compartment. Despite the extensive traumatic area, the excellent limb perfusion –as documented with the preservation of palpable distal pulses- enabled the complete primary healing after months, given regular follow-up on an outpatient basis to provide tissue debridement when needed and confirm absence of infection. The images present the wound healing of the fasciotomy (A) after 15 days, 1,2,3,5 and 6 months (B-F), respectively.

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Figure 2.

First and second digit amputation of the right foot due to gangrene. The patient was submitted to successful femoro-distal bypass surgery. Open trauma healing after months following palpable pulse preservation over the posterior tibial artery and accompanied by wound debridement to prevent trauma infections, after 20 days, 1, 2, 3, 4 and 6months, respectively (A-F).

One should keep in mind that peripheral arterial disease has been reported in approximately 65% of diabetic patients while Vouillarmet et al reported that the ulcer-healing rate following successful revascularization can reach 91% at 1-year, significantly improved compared to patients without revascularization.^4,5 Revascularization techniques to manage arterial ulcers include endovascular techniques, open surgery or hybrid interventions. Bypass surgery with venous graft to popliteal or distal arteries remains the gold standard of revascularization, but may be limited by patient risk, suitable target and conduit availability. Infrapopliteal angioplasty for eligible lesions show acceptable results but restenosis rates after endovascular interventions in these vessels may be high. The indication of revascularization include chronic limb-threatening ischemia (CTLI) as manifested with rest pain and/or and tissue loss (gangrene) while the type of revascularization is determined by the number and location of atherosclerotic lesions according to TASC classification, the Wound, Ischemia, and foot Infection (WIfI) and the Global Limb Anatomic Staging System (GLASS) as well as the patient's general health status.^5,6

Obviously, wound healing by secondary-intension based solely on optimal tissue perfusion with distal palpable pulses is time-consuming and should be weighed against the aforementioned modalities. The necessity for strict, regular outpatient surveillance program to check on the wound hygiene at home, absence of infection and maintenance of palpable pulses should be explained in detail to the patient before obtaining informed consent. It is imperative to say that regular wound and perfusion inspection should be conducted by vascular surgeons or trained vascular nurses familiar with assessment and measurement of ankle-brachial index, estimation of Doppler waveforms and experience with management of ischemic wounds, documenting also their size and healing progression.^7-9 No matter how fundamental these principles are, we often witness cases admitted for vascular consultation due to “improper healing or progression to gangrene” without pulpable distal pulses but with a “high ankle-brachial index” which turns out to be falsely high, eg due to medial calcification of the crural vessels accompanying diabetes or end-stage renal disease. Our demonstrated representative examples remind -and underscore- to all practitioners involved in wound management the importance of the detection of palpable pulses; no limb with trauma/ulcer and non-palpable distal pulses nor triphasic Doppler signal should be delayed for vascular consultation.