Skip to main content
SpringerLink
Log in

Predicting Wound Healing in the Diabetic Foot: Measuring Tissue Perfusion

  • Chapter
  • First Online:
Management of Diabetic Foot Complications

  • 255 Accesses

Abstract

In patients with diabetic foot ulceration, the presence of peripheral arterial disease (PAD) significantly increases the risk of failure of wound healing and major lower limb amputation. Detecting PAD in people with diabetes can present a challenge. This chapter will discuss commonly used and emerging tests of perfusion, discussing the strengths and weaknesses and their role in clinical practice. Ankle brachial pressure index (ABPI) is of limited utility in patients with diabetic foot ulceration owing to vessel wall calcification. Digital arteries are often spared from the calcification seen in the tibial arteries meaning that absolute toe pressure or toe brachial pressure indices (TBPI) can be used to measure perfusion. Transcutaneous oxygen measurement (TcPO2) measures the levels of oxygen in the tissues below the skin and is an indirect measure of blood flow in the tissues. TcPO2 measurements can be affected by localised oedema, infection and inflammation which can reduce its reliability in some patients. Combining perfusion measures with other factors such as infection and wound characteristics allows for improved prediction of wound healing and/or major amputation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51(5):747–55.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Elgzyri T, Larsson J, Thorne J, Eriksson KF, Apelqvist J. Outcome of ischemic foot ulcer in diabetic patients who had no invasive vascular intervention. Eur J Vasc Endovasc Surg. 2013;46(1):110–7.

    Article  CAS  PubMed  Google Scholar 

  3. Richter L, Freisinger E, Luders F, Gebauer K, Meyborg M, Malyar NM. Impact of diabetes type on treatment and outcome of patients with peripheral artery disease. Diab Vasc Dis Res. 2018;15(6):504–10.

    Article  PubMed  Google Scholar 

  4. Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, et al. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3277.

    PubMed  Google Scholar 

  5. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, et al. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg. 2007;33(4):453–60.

    Article  CAS  PubMed  Google Scholar 

  6. Bajwa A, Wesolowski R, Patel A, Saha P, Ludwinski F, Smith A, et al. Assessment of tissue perfusion in the lower limb. Circ Cardiovasc Imaging. 2014;7(5):836–43.

    Article  PubMed  Google Scholar 

  7. LoGerfo FW, Coffman JD. Current concepts. Vascular and microvascular disease of the foot in diabetes. Implications for foot care. N Engl J Med. 1984;311(25):1615–9.

    Article  CAS  PubMed  Google Scholar 

  8. Sharma S, Schaper N, Rayman G. Microangiopathy: is it relevant to wound healing in diabetic foot disease? Diabetes Metab Res Rev. 2020;36(Suppl 1):e3244.

    PubMed  Google Scholar 

  9. Hinchliffe RJ, Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, et al. Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(Suppl 1):e3276.

    PubMed  Google Scholar 

  10. Bunt TJ, Holloway GA. TcPO2 as an accurate predictor of therapy in limb salvage. Ann Vasc Surg. 1996;10(3):224–7.

    Article  CAS  PubMed  Google Scholar 

  11. Tern PJW, Kujawiak I, Saha P, Berrett TB, Chowdhury MM, Coughlin PA. Site and burden of lower limb atherosclerosis predicts long-term mortality in a cohort of patients with peripheral arterial disease. Eur J Vasc Endovasc Surg. 2018;56(6):849–56.

    Article  PubMed  Google Scholar 

  12. Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, et al. Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3278.

    PubMed  Google Scholar 

  13. Yamada T, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Takahashi M, et al. Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs—comparison with other noninvasive diagnostic methods. J Vasc Surg. 2008;47(2):318–23.

    Article  PubMed  Google Scholar 

  14. Terasaki H, Inoue Y, Sugano N, Jibiki M, Kudo T, Lepantalo M, et al. A quantitative method for evaluating local perfusion using indocyanine green fluorescence imaging. Ann Vasc Surg. 2013;27(8):1154–61.

    Article  PubMed  Google Scholar 

  15. Venermo M, Settembre N, Alback A, Vikatmaa P, Aho PS, Lepantalo M, et al. Pilot assessment of the repeatability of indocyanine green fluorescence imaging and correlation with traditional foot perfusion assessments. Eur J Vasc Endovasc Surg. 2016;52(4):527–33.

    Article  CAS  PubMed  Google Scholar 

  16. Wallin L, Bjornsson H, Stenstrom A. Fluorescein angiography for predicting healing of foot ulcers. Acta Orthop Scand. 1989;60(1):40–4.

    Article  CAS  PubMed  Google Scholar 

  17. Jens S, Marquering HA, Koelemay MJ, Reekers JA. Perfusion angiography of the foot in patients with critical limb ischemia: description of the technique. Cardiovasc Intervent Radiol. 2015;38(1):201–5.

    Article  PubMed  Google Scholar 

  18. Reekers JA, Koelemay MJ, Marquering HA, van Bavel ET. Functional imaging of the foot with perfusion angiography in critical limb ischemia. Cardiovasc Intervent Radiol. 2016;39(2):183–9.

    Article  PubMed  Google Scholar 

  19. Reed GW, Young L, Bagh I, Maier M, Shishehbor MH. Hemodynamic assessment before and after endovascular therapy for critical limb ischemia and association with clinical outcomes. JACC Cardiovasc Interv. 2017;10(23):2451–7.

    Article  PubMed  Google Scholar 

  20. Pardo M, Alcaraz M, Bernal FL, Felices JM, Achel GD, Canteras M. Transcutaneous oxygen tension measurements following peripheral transluminal angioplasty procedure has more specificity and sensitivity than ankle brachial index. Br J Radiol. 2015;88(1046):20140571.

    Article  CAS  PubMed  Google Scholar 

  21. Gunnarsson T, Lindgren H, Gottsater A, Parsson H. Intraprocedural transcutaneous oxygen pressure and systolic toe pressure measurements during and after endovascular intervention in patients with chronic limb threatening ischaemia. Eur J Vasc Endovasc Surg. 2021;62(4):583–9.

    Article  PubMed  Google Scholar 

  22. Sommerset J, Karmy-Jones R, Dally M, Feliciano B, Vea Y, Teso D. Plantar acceleration time: a novel technique to evaluate arterial flow to the foot. Ann Vasc Surg. 2019;60:308–14.

    Article  PubMed  Google Scholar 

  23. Teso D, Sommerset J, Dally M, Feliciano B, Vea Y, Jones RK. Pedal acceleration time (PAT): a novel predictor of limb salvage. Ann Vasc Surg. 2021;75:189–93.

    Article  PubMed  Google Scholar 

  24. Montero-Baker MF, Au-Yeung KY, Wisniewski NA, Gamsey S, Morelli-Alvarez L, Mills JL Sr, et al. The First-in-Man “Si Se Puede” Study for the use of micro-oxygen sensors (MOXYs) to determine dynamic relative oxygen indices in the feet of patients with limb-threatening ischemia during endovascular therapy. J Vasc Surg. 2015;61(6):1501–10.e1.

    Article  PubMed  Google Scholar 

  25. Simons JP, Goodney PP, Nolan BW, Cronenwett JL, Messina LM, Schanzer A, et al. Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia. J Vasc Surg. 2010;51(6):1419–24.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. The Society for Vascular Surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220–34.

    Article  PubMed  Google Scholar 

  27. Zhan LX, Branco BC, Armstrong DG, Mills JL Sr. The Society for Vascular Surgery lower extremity threatened limb classification system based on Wound, Ischemia, and foot Infection (WIfI) correlates with risk of major amputation and time to wound healing. J Vasc Surg. 2015;61(4):939–44.

    Article  PubMed  Google Scholar 

  28. Cull DL, Manos G, Hartley MC, Taylor SM, Langan EM, Eidt JF, et al. An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system. J Vasc Surg. 2014;60(6):1535–41.

    Article  PubMed  Google Scholar 

  29. Mathioudakis N, Hicks CW, Canner JK, Sherman RL, Hines KF, Lum YW, et al. The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing but not major amputation in patients with diabetic foot ulcers treated in a multidisciplinary setting. J Vasc Surg. 2017;65(6):1698–705 e1.

    Article  PubMed  Google Scholar 

  30. Hicks CW, Canner JK, Mathioudakis N, Sherman R, Malas MB, Black JH 3rd, et al. The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification independently predicts wound healing in diabetic foot ulcers. J Vasc Surg. 2018;68(4):1096–103.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Translational Health Sciences, Univeristy of Bristol, Bristol, UK

    Robert J. Hinchliffe

  2. Bath & Weston Vascular Network, North Bristol NHS Trust, Bristol, UK

    Robert J. Hinchliffe & Luke Hopkins

Authors
  1. Robert J. Hinchliffe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luke Hopkins
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Robert J. Hinchliffe .

Editor information

Editors and Affiliations

  1. University of Southampton, Southampton, UK

    Clifford P. Shearman

  2. Frimley Health NHS Foundation Trust, Frimley, UK

    Patrick Chong

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Hinchliffe, R.J., Hopkins, L. (2023). Predicting Wound Healing in the Diabetic Foot: Measuring Tissue Perfusion. In: Shearman, C.P., Chong, P. (eds) Management of Diabetic Foot Complications. Springer, Cham. https://doi.org/10.1007/978-3-031-05832-5_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-05832-5_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-05831-8

  • Online ISBN: 978-3-031-05832-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation