Poor Blood Flow Is Often Missed as Cause of Non-healing Wounds
The single most important factor that determines whether a wound will heal is adequate blood flow to the surrounding tissues, or tissue perfusion. Without adequate assessment and correction of vascular issues that could impact blood flow, wounds will not heal—regardless of the treatment plan.
Unfortunately, many general healthcare practitioners don’t have the time, resources, or specialized knowledge to identify and manage peripheral artery disease that may be contributing to poor wound healing. If a wound is not improving after four weeks, or if there are signs of infection or poor circulation, the practitioners should refer the patient to a wound care specialist.
Steps to Identifying Peripheral Artery Disease in Wound Care
It’s essential to assess blood flow in any non-healing wound located anywhere on the body—not just leg ulcers. Examples include:
- Abdominal wounds
- Diabetic foot ulcers
- Pressure injuries such as bedsores
- Wounds resulting from cancer or cancer treatment (such as breast cancer)
The first step is to think anatomically. Try to identify, in your mind, the blood vessel that would be providing the majority of tissue perfusion to the wound. Once you have determined which vessel would be most important, try to determine how to measure tissue perfusion to the wound.
Take, for example, a family medicine practitioner seeing a patient with a slow-healing sore on the lateral ankle. The practitioner may examine the top of the foot, feel a pulse, and determine that circulation is not a problem. However, the artery that provides the majority of flow to the lateral ankle is not the blood vessel on the top of the foot. Therefore, they may perform the pulse exam correctly, but the patient’s wound potentially still does not have adequate blood flow to heal the wound.
After feeling for pulses, take a moment to assess for other symptoms of peripheral artery disease, such as:
- History of cardiac disease
- Lower temperature in one side of the body than the other
- Pain, numbness, aches, or heaviness in the legs, particularly when walking or climbing stairs
- Poor nail growth or decreased hair growth
- Shiny, atrophic skin
If you identify any signs of peripheral artery disease and poor circulation in a patient with a non-healing wound, it’s time to refer to a wound care center. Similarly, if you can’t identify a reason for delayed healing after four weeks, refer to a wound care specialist.
Why Refer Wounds with Poor Circulation to a Wound Care Center
When a circulation problem is suspected or confirmed, a physician’s first instinct may be to refer to interventional radiology, cardiology, or a vascular surgeon. However, in a patient with circulation issues plus a wound, specialized wound care is a more efficient and effective referral. The first thing a wound team evaluates is the vascular status of the patient. In addition, the wound specialist also considers all the other medical and social issues to create a personalized, comprehensive treatment plan.
Interventional radiology and cardiology utilize endovascular procedures involving balloons, stents, and catheters. Vascular surgeons can use both endovascular and open surgical interventions. However, those specialists focus on circulation and often do not address other important aspects of wound care.
Conversely, a wound care specialist serves as a quarterback or project manager. They assess and intervene in all aspects of poor healing—including but not limited to peripheral artery disease. They collaborate with a multidisciplinary team to address the multifaceted nature of non-healing wounds. This may include specialists in vascular medicine, endocrinology, surgery, physical therapy, nutrition, and other fields. This approach results in a more comprehensive plan that addresses all of the issues contributing to delayed wound healing.
At a wound care center, a patient with suspected peripheral artery disease receives a Doppler arterial study as part of the initial workup. The wound care provider orders formal vascular testing if the Doppler or pulse exam is abnormal. The provider then reviews the lab tests and makes the appropriate vascular referral if indicated.
Simultaneously, the wound care specialist, in collaboration with the patient’s primary physician, implements other interventions to address all aspects contributing to the wound, such as:
- Blood pressure control
- Lipid-lowering medications
- Lifestyle modifications such as smoking cessation, diet, and exercise
- Advanced wound treatments, such as hyperbaric oxygen therapy and special wound dressings
This comprehensive approach in people with peripheral artery disease and wounds can save time and resources, as well as limit suffering.
To learn more about assessing and managing underlying peripheral artery disease specifically in diabetic foot ulcers, download a guideline from the Society of Vascular Surgery and the American Podiatric Medical Association.
By William J. Ennis
William J. Ennis, DO, MBA, MMM, CPE, is chief medical officer of Healogics, the nation’s leading provider of advanced wound care. He also serves as the Catherine and Francis Burzik Professor of Wound Healing and Tissue Repair and chief of the Section of Wound Healing at the University of Illinois at Chicago’s Division of Vascular Surgery.