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Proximal and distal arteries must be investigated in compression-associated forefoot ulceration

This article originally appeared in BMJ USA

EDITORWe wish to comment on the description by Chan et al of toe and cleft ulceration of unknown cause in patients undergoing compression bandaging for venous ulcers.

Isolated chronic venous insufficiency and peripheral arterial occlusive disease commonly occur in ageing western populations and may coexist in the aetiology of leg ulcer disease. Ulcers of overt mixed arterial/venous aetiology account for more than 10% of ulcerated limbs.¹ Pulse palpation and resting ankle pressure measurements are routinely used to screen for moderate-to-severe arterial disease in leg ulcer aetiology. These tests cannot be used to exclude mild-to-moderate arterial disease. Exercise stress testing can reveal lesions that may not have appeared significant at rest, but post-exercise ankle pressure measurement is often impractical in this group of patients.²

Foot ischemia may arise from occlusive disease affecting arteries proximal to the ankle and/or in foot vessels.³ Subclinical occlusive disease that may be missed by pulse palpation and resting Doppler pressures may, nevertheless, cause significant distal ischemia on compression therapy.

The validity of "normal foot pulses and ankle pressures" in the rested limb in the presence of compression-associated forefoot ulceration should always be questioned. These patients should undergo further arterial investigation. We use duplex imaging and magnetic resonance angiography (for vessels down to the distal calf) and digital subtraction arteriography (for foot vessels) to exclude arterial disease.

During Doppler-guided compression therapy for venous leg ulceration, the onset or worsening of forefoot ischemia should trigger immediate cessation of compression. The proximal and distal arterial tree of the affected limb should then be thoroughly investigated.

IK Nyamekye, consultant vascular surgeon. 
Worcestershire Acute Hospitals NHS Trust, Worcester Royal Infirmary, Worcester WR5 1HN, UK isaacknyamekye{at}hotmail.com

DC Mitchell, consultant vascular surgeon. 
North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK

KR Poskitt, consultant surgeon. 
East Gloucestershire NHS Trust, Cheltenham General Hospital, Cheltenham GL 53 7AN, UK