Vascular Assessment and Revascularization

To heal, a wound needs oxygen, nutrients and defence cells, all carried by the blood. In people with diabetes, narrowing and blockage of the leg arteries, known as peripheral artery disease, is common. Vascular assessment finds out whether enough blood reaches the foot for the wound to heal. If not, procedures that increase blood flow, called revascularization, are considered.

Why should circulation be checked in every wound?

International guidelines recommend looking for peripheral artery disease in every person with diabetes and a foot wound. Artery disease in diabetes is often silent. Nerve damage masks pain. Typical complaints such as calf pain on walking may be absent. The first sign may be a non-healing wound or a colour change in a toe.

When blood flow is too low:

• The wound may not close despite good care (see non-healing foot wound).
• Antibiotics may not reach the infected area well enough.
• Tissue may struggle to heal after wound cleaning or a small operation.
• Tissue may turn black (see black toe).

A cold foot, pale or bluish skin, hair loss on the foot, or a wound on the toe tips or heel all suggest a circulation problem. However, the absence of these signs does not rule out artery disease.

How is blood flow assessed?

Assessment starts with simple, painless bedside measurements. No single test is enough, and guidelines recommend interpreting several together.

Imaging with contrast dye takes kidney function into account, so tests are chosen for each patient individually.

When is revascularization considered?

According to guidelines, revascularization is considered when blood flow is too low for the wound to heal. For wounds that do not shrink within a few weeks despite appropriate care, a fresh look at the arteries is also recommended, even if the first measurements were not very poor. The decision is not made on measurements alone: wound size, infection, the patient's general condition and expectations are weighed together.

There are two main methods:

Endovascular procedures. A thin catheter is passed into the artery from the groin or the foot. The narrowed section is widened with a balloon and, if needed, a stent is placed. It is usually done under local anaesthesia.

Bypass surgery. The blocked section is bridged, usually with the patient's own vein. It is an open operation.

The choice depends on the location and length of the blockage, the availability of a suitable vein for bypass, the patient's surgical risk and the centre's experience. Guidelines recommend that this decision is made by a vascular team that includes vascular surgery and interventional radiology.

When infection and poor circulation occur together, time is shorter: guidelines recommend that the vascular and surgical teams assess the patient together without delay. The order of urgent steps, such as draining an abscess, and of revascularization is planned for each patient.

Limits and risks

Revascularization may not be possible in every patient and may not always give the expected result. An opened artery can narrow again over time, so regular follow-up is needed. Procedure-related problems can occur, such as bleeding or bruising at the entry site, or an effect of the contrast dye on the kidneys. The team performing the procedure explains these risks to each patient individually.

Better blood flow is one condition for healing, not the whole treatment. Wound debridement, offloading, treatment of infection and blood sugar control continue alongside it.

What can you do?

• If you smoke, get support to stop. It is one of the most valuable steps you can take for your arteries.
• Take your blood thinner, cholesterol and blood pressure medicines as your doctor recommends.
• Keep your blood sugar close to target.
• Do not try to warm your foot with a hot water bottle, a stove or an electric blanket. With reduced feeling, a burn can occur.
• Look at your feet every day. Report any change of colour, coldness or new wound.
• Keep your previous Doppler, angiography and operation reports and bring them to your appointment.

When is it urgent?

Assessment in Istanbul

Prof. Dr. Aytaç Çetinkaya is a specialist in Infectious Diseases and Clinical Microbiology. He assesses the infection side of the wound and asks whether the circulation has been investigated properly. He does not perform revascularization procedures himself. When blood flow is in doubt he recommends assessment by vascular surgery and interventional radiology, and when surgery is needed, working together with orthopaedics and plastic surgery. Treatment of the infection should run within the same plan as the vascular procedure.

Patients from outside Istanbul or abroad can send a photo of the wound and any Doppler, angiography and other reports via WhatsApp and ask for a preliminary review. If an operation has been proposed and you are not sure whether your circulation has been assessed, you can ask for a second opinion. A preliminary review does not replace an examination.