More than 8 million Americans are affected by peripheral arterial occlusive disease (PAOD).¹ The presence of PAOD can seriously inhibit the ability of a lower extremity ulceration to heal. Many wounds will not heal unless adequate arterial perfusion is reestablished. Traditionally, revascularization was achieved by open surgical bypass,² but recent advances in percutaneous angioplasty and stenting techniques have provided new options. These innovations offer promising new treatment alternatives for those patients who were previously considered unsuitable candidates for open procedures or for those whose wounds overlie the path of standard surgical incisions.^3,4 Clinicians must be able to recognize wounds whose healing potential is compromised by PAOD so that revascularization can be undertaken before tissue loss progresses to the point that limb preservation is not an option.

Patient Evaluation

Identification of patients with inadequate perfusion for healing is critical. Initial assessment of any wound begins with a complete history and a thorough physical examination.

     History. The existence of risk factors for PAOD should alert the clinician to the possibility of an arterial insufficiency component that may adversely affect wound healing. Commonly identified risk factors include diabetes mellitus, coronary artery disease, hyperlipidemia, cigarette smoking, and hypertension.⁵

     Reports of intermittent claudication should increase the clinician’s suspicion of PAOD. Claudication is reproducible leg pain that occurs when a stenotic or occlusive lesion prevents sufficient arterial blood flow from meeting the increased metabolic needs of an exercising muscle.⁶ Classically, pain or cramping occurs repeatedly in the posterior calf after walking approximately the same distance and is relieved by rest. Claudication pain may also occur in the posterior thigh, buttock, or hip, and rarely in the foot.⁷

     Ischemic rest pain may occur in an advanced disease state. This is severe pain, typically localized in the dorsal aspects of the toes and distal forefoot.⁶ Ischemic rest pain is experienced most frequently at night when the extremities are elevated in bed. The pain is reduced with dependency and affected patients will often hang their leg over the side of the bed or get up to walk in an effort to relieve the pain.

     Current and previous wound care regimens and the clinical response should be reviewed in detail. Reasonable regimens with increasing tissue loss should also alert the clinician that a vascular etiology should be considered. A history of revascularization with a lack of response to treatment should warrant reassessment of the revascularization for technical adequacy and the patient’s foot perfusion.

     Physical examination. Physical examination findings that are indicative of PAOD include atrophic skin changes, which suggest a lack of adequate arterial perfusion. The skin covering the lower extremity and foot is thin, taut, and shiny.⁸ Thinning or actual loss of the hair over the distal third of the leg and the foot will typically occur. The skin is cool to the touch, pale, or even mottled, while toenails become thick and dystrophic.

     Extremities affected by PAOD will frequently display Buerger’s sign, characterized by dependent rubor and pallor with elevation from chronic dilatation of the vascular bed.⁶ This physical sign is due to loss of vasomotor control of the microcirculation and is seen in cases of advanced ischemia.⁹ When in a dependent position, a deep, dusky red or “ruddy” flush spreads proximally from the toes over the dorsum of the foot.