The role of hemodynamic measurements in the management of venous and ischemic ulcers.

There is a need for quantitative investigations in the vascular laboratory to manage lower extremity ulcers. The majority of leg ulcers are of venous (45%-60%) or arterial origin (10%-20%). Despite the increasing complexity of new devices used in vascular surgical practice, the anklebrachial pressure index (ABPI) remains the cornerstone for the differential diagnosis of ischemic ulcers. The toe-brachial pressure index and the pole test represent attractive alternative tests especially in patients with diabetes. Color flow Doppler imaging (CFDI) is advantageous over ABPI in cases in which wounds and ulcers prevent the use of a cuff by virtue of their size or location; additionally CFDI technology can detect nonflow limiting lesions, lesions to nonaxial arteries such as the deep femoral artery, or lesions limited to a single tibial artery. Continued improvements in the accuracy of CFDI have prompted some vascular surgeons to replace contrast arteriography in distal bypass procedures. Transcutaneous partial oxygen tension measurement (TcPO(2)) is another noninvasive method that is reliable to select the level of amputation and recommended to determine tissue viability in critically ischemic limbs and in the management of the diabetic foot. CFDI has revolutionized the diagnostic approach to venous disorders and it is considered the gold standard for the assessment of the venous system of the lower limb, causes minimal inconvenience to patients, and is easily repeatable, but it is considered highly operator dependent. Various plethysmography techniques are of limited application in ulcer investigations, because of their difficulty to calibrate signal, unless time measurements such as the postexercise refilling time are used.