Peripheral Vascular Disease - Appendix What is peripheral vascular disease ? What is a vascular ulcer and how do you treat it ? How often does the ulcer need to be treated ? Having an ulcer is a serious condition that can rapidly threaten the foot. Depending on the clinical situation, the doctor and health care team may need to see it everyday. Generally, once stabilized and the patient is doing the dressing everyday, it still needs to be seen and treated every week. Is it safe to debride a vascular ulcer ? If there are signs of poor circulation (eg. weak foot pulses, purplish and cold foot, ankle brachial index less than 0.6, toe pressure less than 50mmHg), it is not safe to debride the wound. It may need to be debrided by a surgeon in an operating theatre. Can vascular disease and neuropathy coexist to make an ulcer worse ? Undoubtedly. Many ulcers occur in people with both neuropathy and peripheral vascular disease. Therefore in the assessment of any vascular ulcer, it is necessary to determine if sensation is also impaired ( and vice versa). When there is significant neuropathy as well as vascular impairment, such ulcer is called a neuro-ischaemic ulcer. Like all vascular ulcers, local treatment needs to be cautious so that tissue is not damaged by excessive debridement. As patient cannot feel pain, more effort should be spent to make sure there is no excessive pressure at the site of the ulcer and infection is treated. If the ulcer does not heal, then blood supply needs to be improved by angioplasty or surgery. Does contact cast have any role ? No. Casting is contraindicated when the blood supply is reduced. What about walking exercise ? Walking is not a good exercise for anyone with a vascular ulcer because it increases the chance of trauma which slows down healing. The patient probably has too much pain to want to do this anyway. Walking should be limited to essential activities. When is surgery indicated ? If a vascular ulcer does not make progress despite optimisation of local treatment and control of infection, it is time to think of investigations and surgical intervention. Clinical judgement and results of tests such as ankle brachial index and toe pressure may also help to decide on earlier intervention. On the other hand, sometimes the cure is worse than the disease. For example, operating on an ischaemic foot may open up new wounds, making the problem worse. Clinical judgement is required.