Background: Chronic lower extremity wounds have become a major challenge to healthcare systems and are a significant source of morbidity and mortality. Assessment of lower extremity perfusion is strongly recommended for non-healing lower extremity wounds. However, there is wide variation in treatment practices and the frequency of vascular assessment in an outpatient setting remains unknown.
Methods: Our retrospective cohort included all adult patients seen in Parkland Hospital’s outpatient foot wound clinic over a six month time period (2/2014-6/2014). Charts were reviewed to collect demographic characteristics, wound characteristics, common vascular risk factors, vascular assessment and subsequent interventions. Peripheral arterial disease was defined as an ankle-brachial index (ABI<0.9) or non-compressible (ABI>1.4). Wounds were characterized as non-healing if there was no evidence of improvement after 3 months of follow up. Statistical analysis was then performed on patients with non-healing wounds and no previous history of peripheral vascular disease.
Results: Our retrospective cohort included a total of 438 patients that were followed for a median of 2.1 years. The population was 70% male with a median age of 56 and a median BMI of 30. The majority of patients were Hispanic (45%) and there was high prevalence of hypertension (82%), hyperlipidemia (59%), diabetes (87%), tobacco use (51%), peripheral vascular disease (36%) and coronary artery disease (19%). Follow up data was missing in 39 patients. Among all patients seen in the foot wound clinic, an ABI was performed in 185 (42%) patients. At 3 months, 170 patients (38%) had evidence of a non-healing wound. After excluding patients with a known history of PVD, an ABI was performed in 27% patients (27 of 99) with non-healing wounds. Those patients undergoing ABIs were older (56 vs 50, p=0.006), had lower BMI (30 vs 34, p=0.04) and higher prevalence of CKD (40% vs 15%, p=0.007). After adjusting for common risk factors both age and CKD were remained statistically significant (p=0.004 and p=0.001, respectively). Among the ABIs performed, 15% (4 of 27) were found to have PAD, 48% (13 of 27) were normal and 37% (10 of 27) had non-compressible disease. Patients with PAD were also more likely to undergo peripheral angiography with intervention compared to patients with (50% vs 7%, p=0.02) and remained statistically significant after adjusting for traditional risk factors (p=0.001)
Discussion: Although the foot wound population has a high rate of vascular risk factors, a vascular assessment was performed in the minority of patients. Patients who underwent vascular assessment and were found to have evidence of ischemia were more likely to undergo subsequent revascularization.