Toe Pressure Measurements in Patients Suspected of Critical Limb Ischemia

An objective hemodynamic assessment is mandatory to confirm Critical Limb Ischemia (CLI). Toe pressure measurement is recommended. We compared toe measurements obtained using the Laser Doppler method (LD) (PERIMED PeriFlux, Sweden) considered as the reference test, with those obtained with a portable device using photoplethysmography (PPG) (Sys Toe Atys Medical, France). A total of 93 (123 legs) patients from 3 French hospitals with a clinical suspicion of CLI were included and had measurements with each device carried out by skilled operators. PPG was unable to provide a measurement in 10 patients. Lin’s Coefficient correlation concordance (CCC) and Bland and Altman’s scatter plot were analyzed for the 83 remaining patients, CCC was .84 95%CI (.77–.89). For detection of CLI, Cohen’s kappa was .67 95%CI (.53–.81). The PPG device is fairly reliable for toe pressure measurement in patients suspected of CLI and could be useful when LD is not available. However, it fails to deliver a measurement in approximately 10% of cases. No conclusion should be made about CLI for these patients when no measurement is obtainable and other methods should be used (LD, transcutaneous oxygen pressure) to assess perfusion of the limbs.

Clinical Efficacy and Safety of Long-Term Compression in Patients with Mixed Arterial and Venous Etiology Ulcers in the Leg

Elastic compressions are standard treatment for leg ulcers of venous etiology. The effect of compressions on ulcers of mixed (arterial or venous) etiology, however, has rarely been studied. The objective of this study was to evaluate the variation in transcutaneous oxygen pressure (TcPO2) in patients with ulcers of mixed arterial or venous etiology treated with 1 month of compression. This prospective cohort study was conducted at a university hospital in France. Patient eligibility was for those attending a consultation of a work-up of a leg ulcer of mixed arterial-venous etiology lasting at least 4 to 6 weeks. Compressions were prescribed according to the hemodynamic status and were evaluated by the ankle-brachial index and toe-brachial index using a decision-making algorithm based on French national guidelines. Quality of life was assessed using the Short-Form 36-Item (SF-36) questionnaire. In total, 32 patients were included between September 30, 2018 and May 31, 2019. A difference was observed between TcPO2 before compression (49.3 ± 13.01 mm Hg) and after 1 month (51.2 ± 15.05 mm Hg), average change 1.9 ± 2.04 mm Hg (p = 0.025). The average ulcer size prior to compression was 49 ± 102 cm2 versus 37 ± 94 cm2 after 1 month of effective compression, corresponding to a reduction of 12 ± 8 cm2 (p < 0.001). There was a reduction in the bodily pain dimension of the SF-36. Compressions adapted to the hemodynamic status led to an increase in TcPO2, a reduction in wound size, and an improvement to bodily pain in patients with leg ulcers of mixed arterial-venous etiology.

The combined impact of ankle–brachial index and transcutaneous oxygen pressure on mortality in patients with type 2 diabetes and foot ulcers

Aims A diabetic foot ulcer (DFU) is associated with increased cardiovascular risk and mortality, independently of ulcer etiology (ischemic, neuro-ischemic or neuropathic). Ankle–brachial index (ABI) is the most commonly used test when diagnosing peripheral macrovascular disease and is a well-known marker for increased cardiovascular risk. Transcutaneous oxygen pressure (TcPO2) is considered to better evaluate microvascular function and has in previous studies shown correlations with both wound healing and survival. The aim of this study was to evaluate the combined impact of a low TcPO2 (<30 mmHg) and a pathological ABI (<0.9 or ≥1.4) on three-year mortality in patients with DFU. Methods Type 2 diabetes patients aged <90 years, with at least one DFU who underwent vascular assessment with ABI and TcPO2 were screened for participation. The primary endpoint was mortality after three years, assessed from the National Death Registry in Sweden. Results The study enrolled 235 participants with a median age of 76 years. Individuals with either an abnormally high or low ABI in combination with a low TcPO2 had the worst survival rates, with three-year mortality of 54%, compared to 42% in those with one abnormal variable (either ABI or TcPO2), and 21% in those with normal ABI and TcPO2. Conclusions Combining ABI and TcPO2 when risk stratifying DFU patients seems to provide additional predictive information, not only concerning ulcer healing and limb salvage, but also on survival.

Evolution of the TcPO2 values following hyperoxygenated fatty acids emulsion application in patients with diabetic foot disease: results of a clinical trial

Objective: The use of emollients to lubricate dry skin to prevent diabetic foot ulcers (DFUs), especially in neuroischaemic feet, has been recommended. This study analyses the effect of daily topical application of hyperoxygenated fatty acids emulsion on transcutaneous oxygen pressure (TcPO2) in the feet of neuropathic and neuroischaemic patients with diabetes. Method: Patients with diabetes and no active foot ulcer were included in this longitudinal, prospective, non-comparative clinical trial. The evolution of TcPO2 (mmHg) values after the application of the tested emulsion (Corpitol Emulsion, Laboratoires Urgo Medical, France) was evaluated for a three-month period. Modifications of skin features (skin dryness, skin shedding and skin colour) were also analysed. TcPO2 was performed using a TCM400 device (Radiometer, Denmark). Results: A total of 50 patients were included in the study. Patients with neuroischaemia showed a significant increase in TcPO2 values (35.69±13.88mmHg) after two months' application of the tested emulsion that remained at month three (day 60: 42.34±10.98mmHg; p=0.006; day 90: 41.62±10.88mmHg; p=0.011). Skin dryness and shedding showed an improvement from baseline to the end of the study in both groups, secondary to the use of the tested emulsion (p<0.001 and p<0.001, respectively). Skin colour also showed differences from baseline to the final visit in the neuroischaemic patients (p=0.029). Patients with neuropathy did not show any change in skin colour from baseline to the final visit. Conclusions: Analysis of the use of the tested emulsion showed an increase in TcPO2 and an improvement in skin trophism in patients with neuroischaemic foot.

Increasing Transcutaneous Oxygen Pressure in Patients With Neuroischemic Diabetic Foot Ulcers Treated With a Sucrose Octasulfate Dressing: A Pilot Study

Regarding the positive clinical outcomes of sucrose octasulfate impregnated dressing documented in neuroischemic diabetic foot ulcers (DFUs), we aimed to evaluate the microcirculatory status in patients with neuroischemic DFU through the use of sucrose octasulfate dressing. Eleven patients with neuroischemic DFU were included in a prospective pilot study between July 2019 and March 2020. We evaluated the effect in transcutaneous oxygen pressure (TcPO2; mm Hg) values within the use of a sucrose octasulfate dressing in the course of the healing process of neuroischemic DFUs (UrgoStart Contact, Laboratoires Urgo Medical). TcPO2 values were assessed at day 0 and monthly until wound healing was achieved. Additionally, wound healing process was evaluated using the Wollina score system and wound area surface, at day 0 and monthly until 20 weeks of follow-up or wound healing first occurred. TcPO2 values showed a significant increase between day 0 (29.45 ± 7.38 mm Hg) and wound closure (46.54 ± 11.45 mm Hg, P = .016), after dressing application. Wollina wound scores showed a significant improvement (4.2 ± 1.7 at day 0 to 5.4 ± 1.3 at the end of the study; P = .004). Median wound area at day 0 was 1.30 cm2, interquartile range [1.60-1] cm2, and 0.5 cm2 at week 4, interquartile range [1.1-0.1], P < .001. Median healing time was 8 weeks, interquartile range [8-5]. Treating a neuroischemic DFU with a sucrose octasulfate dressing in the standard of care showed an increase in skin oxygen pressure.

Multimodal Supervised Exercise Significantly Improves Walking Performances Without Changing Hemodynamic Parameters in Patients With Symptomatic Lower Extremity Peripheral Artery Disease

We evaluated the outcome of multimodal supervised exercise training (SET) on walking performances and different hemodynamic parameters (ankle/toe-brachial index [ABI/TBI], and transcutaneous oxygen pressure [TcPO2]) in patients with symptomatic lower extremity peripheral artery disease (PAD). Whether hemodynamic parameters predict walking performances at baseline and following SET was also investigated. Fontaine stage II PAD’s patients following a 3-month SET were retrospectively included. Hemodynamic parameters and walking performances (pain-free [PFWD], maximal [MWD], and 6-minute [6MWD] walking distance) were measured in each patient. Eighty-five symptomatic PAD patients were included. Following SET, PFWD, MWD, and 6MWD significantly increased (+142%, +94%, +14%; respectively; P ≤ .001). Toe-brachial index significantly increased (MD: 0.04 ± 0.01; P = .02), whereas ABI and TcPO2 did not change significantly. At baseline, patients with higher TBI and TcPO2 performed significantly better (PFWD: β = 0.25, P = .01 for TBI; PFWD: β = 0.30, P = .005, and MWD: β = 0.22, P = .04, for TcPO2). No significant relationship was observed at baseline between ABI and walking performances. Baseline values of hemodynamic parameters did not significantly correlate with changes in walking performances. Multimodal SET significantly improves walking performances. Following SET, no significant changes in ABI and TcPO2 were observed. Toe-brachial index values significantly improved after SET. However, this increase was very modest and its clinical relevance remains questionable. Although baseline TBI and supine TcPO2 values predict baseline walking performances, no association was found between baseline hemodynamic parameters and changes in walking performances following SET.