Skin perfusion pressure as a predictor of ischemic wound healing potential (Review)

  • Authors:
    • Xuanliang Pan
    • Guoxian Chen
    • Pan Wu
    • Chunmao Han
    • Jon Kee Ho
  • View Affiliations

  • Published online on: February 13, 2018     https://doi.org/10.3892/br.2018.1064
  • Pages:330-334
Metrics: HTML 0 views | PDF 0 views     Cited By (CrossRef): 0 citations

Abstract

Skin perfusion pressure (SPP) is the blood pressure that is the requisite for the restoration of microcirculatory or capillary flow following controlled occlusion and subsequent flow return. The purpose of the current review was to evaluate the value of SPP for the prediction of wound healing in patients with limb ischemia. Articles published up to January 31, 2017 were searched in the PubMed database and Chinese database CNKI, using the keywords of ‘skin perfusion pressure’, ‘limb ischemia’ and ‘wound healing’. Articles were obtained and reviewed to analyze the predictive value of SPP with regard to the healing potential of ischemia wounds on limbs. Three different types of techniques are currently used for the measurement of SPP, namely radioisotope clearance, photoplethysmography and laser Doppler, with laser Doppler as the most widely applied technique, due to its noninvasiveness and ease of operability. SPP may effectively assess wound healing potential in ischemic limbs with high sensitivity and specificity; however, its optimum cut‑off point remains uncertain. Compared with other noninvasive microcirculatory assessment tools including ankle‑brachial index, toe blood pressure and transcutaneous oxygen pressure, SPP has its advantages including that it is not affected by vascular calcification, anatomical structure or patient condition. In conclusion, SPP may be used as an index to accurately predict wound healing in patients with limb ischemia. However, it is difficult to determine the optimum cut‑off of SPP due to the limitations of current data. Further study is necessary to confirm the optimum cut‑off value of SPP in predicting wound healing potential.

Introduction

In general, wounds heal rapidly in an ideal local environment. However, the process of healing is affected by various factors, including wound type, which encompasses diabetes ulcers, pressure ulcers, radiation injuries and peripheral vascular diseases. Limb ischemia decreases perfusion and oxygenation to skin cells in the distal extremities, leading to cell death and ulceration (1). Patients with ischemic ulcers often suffer from at-rest pain and may develop gangrene (1). Previous studies have demonstrated that negative pressure wound therapy may accelerate wound healing by promoting blood perfusion (2,3). However, revascularization to restore perfusion is critical for the treatment and prevention of ischemic ulcers in different clinical guidelines (4,5).

It is a challenge for clinicians to predict the wound healing potential of ischemic limbs, and to assess the necessity of amputation, particularly in patients with diabetes, whose ankle artery pressure may be artificially elevated due to arterial calcification (6). Skin perfusion pressure (SPP) is a noninvasive technique of assessing tissue viability (7). Previous studies have demonstrated that SPP is useful in the prediction of wound healing in limb ischemia (8,9); however, key points of its clinical application require further investigation. The present article is a review of the role of SPP in predicting wound healing in patients with limb ischemia. A comparison with other noninvasive techniques assessing peripheral circulation is also provided.

Literature search

Articles published up to January 31, 2017 were searched in the PubMed database (https://www.ncbi.nlm.nih.gov/pubmed) and Chinese database CNKI (http://www.cnki.net/), using the keywords of ‘skin perfusion pressure’, ‘limb ischemia’ and ‘wound healing’, to identify relevant studies reported in the English or Chinese language. All articles reporting the treatment of patients with limb ischemia in which SPP was measured were reviewed. Major information and findings in this area were summarized.

Measurement of SPP

The measurement of SPP was first introduced in the 1960s (10,11). There are currently three different techniques for SPP measurement, namely radioisotope clearance, photoplethysmography and laser Doppler, the principles of which are the same (6). In brief, SPP is measured by gradually decreasing the inflation cuff pressure and observing the washout of the isotope, the reappearance of pulsatile flux or the movement of red blood cells at the site of measurement (6). The minimal external counter pressure on the underlying skin exerted by the pressure cuff is defined as the SPP, above which skin blood flow ceases (6).

Radioisotope clearance was the earliest technique for detecting SPP, which used to be considered as the ‘gold standard’ for measuring SPP, and a reliable method for predicting amputation and ischemic ulcer healing (1214). However, this method was not widely used due to the complexity of the measurement process and the need for injection of radionuclides. In 1987, Castronuovo et al (15) reported a novel noninvasive technique for measuring SPP, which could be performed in minutes using a laser Doppler probe. There was a high correlation of measurement accuracy for SPP when the radioisotopic and laser Doppler methods were compared (16). Photoplethysmography determination has also been used to measure SPP (17,18). However, in a study performed by Malvezzi et al (16), the results were not consistent with those of the previous studies (17,18) reporting the successful determination of SPP using photoplethysmography.

Laser Doppler is fast, effective and easy-to-operate, and is the most widely used method of measuring SPP (19). In recent years, the majority of research on SPP has been conducted using laser Doppler (7). In addition to its use in the diagnosis of critical limb ischemia (CLI) (20), in evaluating the severity of ischemia (2124), in the selection of the amputation plane (25), and in predicting wound healing, SPP is also used to evaluate the therapeutic efficacy of arterial revascularization surgery (26,27), endovascular therapy (28), and medicines used for the treatment of peripheral artery disease (PAD) and CLI (29,30). In a previous study, Watanabe et al (31) revised the laser Doppler technology, and SPP was measured using a thermostatic heating probe. It was demonstrated that this was useful for improving the detectability of SPP in ischemic limbs, and that an increase in SPP following heating may be a potential predictor of limb ischemia.

Predictive value of SPP in wound healing during limb ischemia

Numerous studies have demonstrated that SPP may effectively predict the wound healing potential of ischemic limbs (6,89,25), but the optimum cut-off values of SPP for predictive accuracy remain to be determined.

In a previous meta-analysis by our group (19), relevant studies were searched with the following inclusion criteria: i) Randomized controlled trials, two-arm prospective studies or retrospective studies; ii) patients with limb ischemia; iii) SPP was measured; and iv) studies reporting quantitative outcome data on sensitivity and specificity of SPP. There were 5 studies that met the inclusion criteria, of which 3 examined a cut-off of 30 mmHg and 2 examined a cut-off of 40 mmHg, as described previously (19). This meta-analysis indicated that SPP is an index with sufficient sensitivity and specificity for the prediction of wound healing in patients with limb ischemia.

The earliest study included in the meta-analysis was published in 1995 and examined patients treated with above- and below-knee amputations (25). The results of this study demonstrated that SPP ≥30 mmHg predicted complete healing in 90% of cases, while SPP <30 mmHg predicted the failure of healing in 75% of cases. Also analyzed was a study by Castronuovo et al (20) in 1997, which studied 61 limbs with non-healing foot ulcers, and determined that the sensitivity of SPP <30 mmHg as a diagnostic test of CLI was 85%, while its specificity was 73%; the overall diagnostic accuracy of the diagnostic criterion of SPP <30 mmHg for critical limb ischemia was 79.3%. Also reported previously (19) was the study by Yamada et al (6) in 2008, which examined 403 limbs with arteriosclerosis obliterans in 211 patients, half of whom had diabetes or were treated with dialysis. Receiver operating characteristic (ROC) curve analysis suggested that an SPP of 40 mmHg had a sensitivity of 72% and specificity of 88% for the prediction of wound healing. Subsequent to this, Urabe et al (32) measured SPP in 62 limbs of 53 patients, and a value of 40 mmHg was adopted for clinical decision-making. All the patients were treated with conservative therapy, and outcomes at 1 month were categorized as ‘improved’ or ‘no change or worse’, while the fate of wounds was determined as ‘healed’ or ‘not healed’. The SPP ≥40 mmHg examined in the study had a sensitivity of 75.0% and specificity of 82.6% in predicting the 1-month outcomes. Furthermore, logistic regression analysis revealed that SPP ≥40 mmHg was an independent predictor of improved outcome with an accuracy of 80.6% and an odds ratio of 14.2 (95% confidence interval: 3.6–55.8; P<0.0001). The criterion of SPP ≥40 mmHg to predict the fate of wounds had a sensitivity of 61.1%, a specificity of 79.5% and an accuracy of 74.2% (19,32). The most recently published study of the meta-analysis was reported by Utsunomiya et al (9) in 2014, in which 123 limbs in 113 patients who had undergone successful balloon angioplasty with or without stenting were examined. ROC analysis indicated that the optimal SPP cut-off for predicting wound healing was 30 mmHg, with a sensitivity of 81.4% and a specificity of 69.2%. Notably, the results confirmed that SPP was an independent predictor of wound healing and suggested that the probability of wound healing with SPP values >30, >40 and >50 mmHg were 69.8, 86.3 and 94.5%, respectively (9).

Other studies were noted in our previous meta-analysis (19), despite not meeting the inclusion criteria, that also examined the predictive value of SPP in wound healing. For instance, Watanabe et al (33) retrospectively examined 19 lower limbs in 18 patients who had undergone arterial reconstruction for CLI, and identified that an SPP ≥30 mmHg was a requisite for wound healing. Also noteworthy is a previous prospective, single center comparative study, in which SPPs in 100 patients with chronic extremity wounds were examined, which also suggested that SPP with a value ≥30 mmHg was a useful positive independent predictor of wound healing potential (8). Furthermore, Tsuji et al (34) retrospectively examined 47 patients with 69 ischemic limbs with foot ulcers or gangrene, and observed that SPP measurement was useful for predicting wound healing in the presence of CLI; the results indicated that SPP ≥35 mmHg was a requisite for wound healing, while SPP <35 mmHg indicated that a peripheral arterial reconstruction was necessary prior to debridement. As we highlighted previously (19), Okamoto et al (28) performed an analysis of patients who were treated with endovascular therapy due to critical limb ischemia based on the data of the OLIVE registry, and the results indicated that postprocedural SPP was significantly correlated with 1-year amputation-free survival, modified major adverse limb events and wound healing.

It is difficult to determine the optimum cut-off of SPP in the prediction of wound healing in CLI patients due to the limitations of current literature. Firstly, few studies measured the cut-off of SPP, and inconsistencies exist among these (19). Secondly, the numbers of patients in the studies were relatively small and the treatment of patients varied among debridement/conservative management, amputation and endovascular treatment (19). Further studies with larger samples are necessary to confirm the findings.

Comparison of SPP with other noninvasive methods for assessing peripheral circulation

Ankle-brachial index (ABI) is the most commonly used and internationally recognized method for evaluation of peripheral circulation. However, it may fail to accurately indicate the severity of peripheral ischemia if the underlying vessels are calcified in patients with long-standing diabetes, renal failure or other disorders resulting in vascular calcification, or if there is an extensive distal arterial lesion below the ankle (6,35). In these instances, ABI values are falsely elevated as calcification in the arterial wall makes the artery noncompressible (36). In a consensus document (1), ABI was recommended to confirm the diagnosis of leg ulcers, being assigned the highest level for evidence and the highest level for recommendation in the Strength of Recommendation Taxonomy (37). Recommended thresholds for ABI were the following: Values ≥0.9 and ≤1.3 are in the normal range; values <0.9 are consistent with the presence of arterial disease; values ≤0.5 are consistent with significant peripheral arterial disease; and values ≥1.3 in those with diabetes should be followed by Duplex ultrasound imaging of the leg arteries to exclude artifactual high values (1). Diabetes is a major risk factor for a high (>1.40) ABI (38). Patients with high ABI should be considered as PAD-equivalent, as there is a high prevalence of occlusive PAD in such cases (38). Castronuovo et al (20) noted in their study that ABI was not predictive of the demand for reconstruction or major amputation, or the outcome of conservative local therapy. For patients with incompressible tibial arteries, an alternative is to measure toe blood pressure (TBP), which rarely gives false positive results in incompressible legs (6,39). TBP provides an accurate measurement of distal limb systolic pressures in vessels that do not typically become non-compressible (35). TBP is tested by placing a small cuff around the base of the toe with a digital flow sensor beyond the cuff (40,41). However, it requires a noninvasive vascular laboratory testing with standard environmental conditions, expertise and equipment necessary to make the measurement (35). Additionally, it may be impossible to measure TBP while there are inflammatory lesions, ulceration or tissue defects on the toes. SPP measured in the foot correlates well with TBP and may be substituted for TBP when TBP cannot be measured (42).

Measurement of transcutaneous oxygen pressure (TcPO2) is another method to determine the severity of lower-limb ischemia. TcPO2 is measured using skin surface sensors at 43–45°C. It has been reported to be accurate in noncompressible artery patients and in diabetes patients (43,44). Additionally, a TcPO2 level below a cut-off of 20 or 30 mmHg was an independent predictor of complications during chronic wound healing (45). In a meta-analysis by Nishio et al (46), TcPO2 values of 20 and 30 mmHg were considered appropriate cut-off values for deciding the level of limb amputation and predicting wound healing following amputation, respectively. However, the results of TcPO2 may be unreliable as they can be influenced by various physiological, methodological and technical factors, including room temperature, patient status prior to examination, smoking and caffeine intake, and local skin integrity (6). The prospective single center comparative study by Lo et al (8) evaluated TcPO2 and SPP test results in 100 patients with chronic extremity wounds and identified that SPP alone more successfully predicted wound outcome in 87% of the cohort, compared with TcPO2 with a rate of 64% (P<0.0002). Furthermore, SPP had a higher sensitivity in the prediction of wound healing compared with that of TcPO2 (90 vs. 66%; P<0.0001) (8). Thus, it is recommended that SPP should be continuously applied and investigated in wound assessment protocols and other microperfusion assessments as a reliable and objective measurement tool (8). Okamoto et al (47) compared the four noninvasive methods with results of multidetector-row computed tomography in patients with occlusive PAD, and the sensitivity and specificity of each method was calculated via ROC analysis. The results suggested that SPP was the most useful tool for detecting PAD with an accuracy of 84.9%. However, as previously established, wound healing prediction depends on the set cut-off value and endpoint. Since there was no equivalent standard for the cut-off settings of different methods in these studies, the comparisons between the results were questionable.

Conclusions

In conclusion, laser Doppler is the most widely used method for the determination of SPP. Overall the advantages of SPP measurement include noninvasiveness, high reproducibility and independence from the influence of vascular calcification compared with other indices for peripheral circulation assessment. Furthermore, SPP is an accurate predictor of wound healing potential in patients with limb ischemia, but the optimum cut-off value is controversial at present. Further studies are required to clarify several key issues in the clinical application of SPP, including a reliable cut-off value.

Acknowledgements

Not applicable.

Funding

The present work was supported by the Zhejiang Medical and Health Science and Technology Plan Project funds (grant nos. 2016KYB115 and 2017KY361).

Availability of data and materials

The datasets reviewed in the current report are available from the corresponding author on reasonable request.

Authors' contributions

CH and GC were responsible for study design. XP, PW and JKH performed data collection and analysis. XP and PW were responsible for manuscript writing. GC, CH and JKH were responsible for revision of the manuscript. XP checked the integrity of the manuscript throughout.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

References

1 

Mani R, Margolis DJ, Shukla V, Akita S, Lazarides M, Piaggesi A, Falanga V, Teot L, Xie T, Bing FX, et al: Optimizing Technology Use for Chronic Lower-Extremity Wound Healing: A Consensus Document. Int J Low Extrem Wounds. 15:102–119. 2016. View Article : Google Scholar : PubMed/NCBI

2 

Ma Z, Li Z, Shou K, Jian C, Li P, Niu Y, Qi B and Yu A: Negative pressure wound therapy: Regulating blood flow perfusion and microvessel maturation through microvascular pericytes. Int J Mol Med. 40:1415–1425. 2017. View Article : Google Scholar : PubMed/NCBI

3 

Li Z, Wang Q, Mi W, Han M, Gao F, Niu G and Ma Y: Effects of negative-pressure wound therapy combinedwith microplasma on treating wounds of ulcer and the expression of heat shock protein 90. Exp Ther Med. 13:2211–2216. 2017. View Article : Google Scholar : PubMed/NCBI

4 

Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, et al Society for Cardiovascular Angiography and Interventions, ; Society of Interventional Radiology, ; Society for Vascular Medicine, ; Society for Vascular Surgery, : 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 58:2020–2045. 2011. View Article : Google Scholar : PubMed/NCBI

5 

Hopf HW, Ueno C, Aslam R, Burnand K, Fife C, Grant L, Holloway A, Iafrati MD, Mani R, Misare B, et al: Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair Regen. 14:693–710. 2006. View Article : Google Scholar : PubMed/NCBI

6 

Yamada T, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Takahashi M and Kawanishi J: Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs - comparison with other noninvasive diagnostic methods. J Vasc Surg. 47:318–323. 2008. View Article : Google Scholar : PubMed/NCBI

7 

Pan XL and Han CM: Advances in the research on effect of detecting skin perfusion pressure in clinic. Zhonghua Shao Shang Za Zhi. 32:702–704. 2016.(In Chinese). PubMed/NCBI

8 

Lo T, Sample R, Moore P and Gold P: prediction of wound healing outcome using skin perfusion pressure and transcutaneous oximetry: A single-center experience in 100 patients. Wounds. 21:310–316. 2009.PubMed/NCBI

9 

Utsunomiya M, Nakamura M, Nagashima Y and Sugi K: Predictive value of skin perfusion pressure after endovascular therapy for wound healing in critical limb ischemia. J Endovasc Ther. 21:662–670. 2014. View Article : Google Scholar : PubMed/NCBI

10 

Nilsén R, Dahn I, Lassen NA and Westling H: On the estimation of local effective perfusion pressure in patients with obliterative arterial disease by means of external compression over a Xenon-133 depot. Scand J Clin Lab Invest Suppl. 99:29–30. 1967.PubMed/NCBI

11 

Lassen NA, Larsen OA, Sorensen AW, Hallböök T, Dahn I, Nilsén R and Westling H: Conservative treatment of gangrene using mineralocorticoid-induced moderate hypertension. Lancet. 1:606–609. 1968. View Article : Google Scholar : PubMed/NCBI

12 

Lepäntalo M, Isoniemi H and Kyllönen L: Can the failure of a below-knee amputation be predicted? Predictability of below-knee amputation healing. Ann Chir Gynaecol. 76:119–123. 1987.PubMed/NCBI

13 

Duncan HJ and Faris IB: Skin vascular resistance and skin perfusion pressure as predictors of healing of ischemic lesion of the lower limb: Influences of diabetes mellitus, hypertension, and age. Surgery. 99:432–438. 1986.PubMed/NCBI

14 

Holstein P, Sager P and Lassen NA: Wound healing in below-knee amputations in relation to skin perfusion pressure. Acta Orthop Scand. 50:49–58. 1979. View Article : Google Scholar : PubMed/NCBI

15 

Castronuovo JJ Jr, Pabst TS, Flanigan DP and Foster LG: Noninvasive determination of skin perfusion pressure using a laser Doppler. J Cardiovasc Surg (Torino). 28:253–257. 1987.PubMed/NCBI

16 

Malvezzi L, Castronuovo JJ Jr, Swayne LC, Cone D and Trivino JZ: The correlation between three methods of skin perfusion pressure measurement: Radionuclide washout, laser Doppler flow, and photoplethysmography. J Vasc Surg. 15:823–829; discussion 829–830. 1992. View Article : Google Scholar : PubMed/NCBI

17 

Holstein P, Nielsen PE, Lund P, Gyntelberg F and Poulsen HL: Skin perfusion pressure on the legs measured as the external pressure required for skin reddening after blanching: A photo-electric technique compared to isotope washout. Scand J Clin Lab Invest. 40:535–543. 1980. View Article : Google Scholar : PubMed/NCBI

18 

Ovesen J and Støckel M: Measurement of skin perfusion pressure by photoelectric technique - an aid to amputation level selection in arteriosclerotic disease. Prosthet Orthot Int. 8:39–42. 1984.PubMed/NCBI

19 

Pan X, You C, Chen G, Shao H, Han C and Zhi L: Skin perfusion pressure for the prediction of wound healing in critical limb ischemia: A meta analysis. Arch Med Sci. 2016.simplehttps://doi.org/10.5114/aoms.2016.62220 View Article : Google Scholar : PubMed/NCBI

20 

Castronuovo JJ Jr, Adera HM, Smiell JM and Price RM: Skin perfusion pressure measurement is valuable in the diagnosis of critical limb ischemia. J Vasc Surg. 26:629–637. 1997. View Article : Google Scholar : PubMed/NCBI

21 

Tanaka A, Sakakibara M, Nishimura H, Asano M, Kariya T, Masamoto D, et al: Evaluation for hypoperfusion distal to arteriovenous vascular access using skin perfusion pressure in fingers. J Vasc Access. 15:29–32. 2014. View Article : Google Scholar : PubMed/NCBI

22 

Sueki S, Sakurada T, Miyamoto M, Tsuruoka K, Matsui K, Sato Y, Shibagaki Y and Kimura K: Change in skin perfusion pressure after the creation of upper limb arteriovenous fistula for maintenance hemodialysis access. Hemodial Int. 18 Suppl 1:S19–S22. 2014. View Article : Google Scholar : PubMed/NCBI

23 

Okubo K, Sato T, Matsubara C, Tsuboi M, Ishii Y and Tojimbara T: Effectiveness of skin perfusion pressure monitoring during surgery for an ischemic steal syndrome associated refractory ulcer. J Vasc Access. 16:163–166. 2015. View Article : Google Scholar : PubMed/NCBI

24 

Hiratsuka M, Koyama K, Yamamoto J, Narita A, Sasakawa Y, Shimogushi H, Ogawa A, Kimura T, Mizuguchi K and Mizuno M: Skin Perfusion Pressure and the Prevalence of Atherothrombosis in Hemodialysis Patients. Ther Apher Dial. 20:40–45. 2016. View Article : Google Scholar : PubMed/NCBI

25 

Adera HM, James K, Castronuovo JJ Jr, Byrne M, Deshmukh R and Lohr J: Prediction of amputation wound healing with skin perfusion pressure. J Vasc Surg. 21:823–828, discussion 828–829. 1995. View Article : Google Scholar : PubMed/NCBI

26 

Kawarada O, Yokoi Y and Higashimori A: Angioplasty of ulnar or radial arteries to treat critical hand ischemia: Use of 3- and 4-French systems. Catheter Cardiovasc Interv. 76:345–350. 2010. View Article : Google Scholar : PubMed/NCBI

27 

Mochizuki Y, Hoshina K, Shigematsu K, Miyata T and Watanabe T: Distal bypass to a critically ischemic foot increases the skin perfusion pressure at the opposite site of the distal anastomosis. Vascular. 24:361–367. 2016. View Article : Google Scholar : PubMed/NCBI

28 

Okamoto S, Iida O, Nakamura M, Yamauchi Y, Fukunaga M, Yokoi Y, Soga Y, Zen K, Hirano K, Suematsu N, et al OLIVE Investigators, : Postprocedural Skin Perfusion Pressure Correlates With Clinical Outcomes 1 Year After Endovascular Therapy for Patients With Critical Limb Ischemia. Angiology. 66:862–866. 2015. View Article : Google Scholar : PubMed/NCBI

29 

Miyashita Y, Saito S, Miyamoto A, Iida O and Nanto S: Cilostazol increases skin perfusion pressure in severely ischemic limbs. Angiology. 62:15–17. 2011. View Article : Google Scholar : PubMed/NCBI

30 

Hidaka S, Kobayashi S, Iwagami M, Isshiki R, Tsutsumi D, Mochida Y, Ishioka K, Oka M, Maesato K, Moriya H, et al: Sarpogrelate hydrochloride, a selective 5-HT(2A) receptor antagonist, improves skin perfusion pressure of the lower extremities in hemodialysis patients with peripheral arterial disease. Ren Fail. 35:43–48. 2013. View Article : Google Scholar : PubMed/NCBI

31 

Watanabe Y, Masaki H, Kojima K, Tabuchi A, Yunoki Y, Furukawa H, Yamasawa T, Takiuchi H, Honda T, Kuwada N, et al: Assessment of the characteristics and detectability of skin perfusion pressure measured using a thermostatic heating probe. Ann Vasc Dis. 6:718–724. 2013. View Article : Google Scholar : PubMed/NCBI

32 

Urabe G, Yamamoto K, Onozuka A, Miyata T and Nagawa H: Skin Perfusion Pressure is a Useful Tool for Evaluating Outcome of Ischemic Foot Ulcers with Conservative Therapy. Ann Vasc Dis. 2:21–26. 2009. View Article : Google Scholar : PubMed/NCBI

33 

Watanabe Y, Onozuka A, Obitsu Y, Komai H, Koizumi N, Saiki N and Shigematsu H: Skin perfusion pressure measurement to assess improvement in peripheral circulation after arterial reconstruction for critical limb ischemia. Ann Vasc Dis. 4:235–240. 2011. View Article : Google Scholar : PubMed/NCBI

34 

Tsuji Y, Hiroto T, Kitano I, Tahara S and Sugiyama D: Importance of skin perfusion pressure in treatment of critical limb ischemia. Wounds. 20:95–100. 2008.PubMed/NCBI

35 

Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA and Fowkes FG; TASC II Working Group, . Inter Society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 45:S5–S67. 2007. View Article : Google Scholar : PubMed/NCBI

36 

Smith FB, Lee AJ, Price JF, van Wijk MC and Fowkes FG: Changes in ankle brachial index in symptomatic and asymptomatic subjects in the general population. J Vasc Surg. 38:1323–1330. 2003. View Article : Google Scholar : PubMed/NCBI

37 

Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B and Bowman M: Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 69:548–556. 2004.PubMed/NCBI

38 

Aboyans V, Ho E, Denenberg JO, Ho LA, Natarajan L and Criqui MH: The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg. 48:1197–1203. 2008. View Article : Google Scholar : PubMed/NCBI

39 

Andersen CA: Noninvasive assessment of lower extremity hemodynamics in individuals with diabetes mellitus. J Vasc Surg. 52:76S–80S. 2010. View Article : Google Scholar : PubMed/NCBI

40 

Høyer C, Sandermann J and Petersen LJ: The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg. 58:231–238. 2013. View Article : Google Scholar : PubMed/NCBI

41 

Williams DT, Price P and Harding KG: The influence of diabetes and lower limb arterial disease on cutaneous foot perfusion. J Vasc Surg. 44:770–775. 2006. View Article : Google Scholar : PubMed/NCBI

42 

Tsai FW, Tulsyan N, Jones DN, Abdel-Al N, Castronuovo JJ Jr and Carter SA: Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia. J Vasc Surg. 32:32–36. 2000. View Article : Google Scholar : PubMed/NCBI

43 

Koch C, Chauve E, Chaudru S, Le Faucheur A, Jaquinandi V and Mahé G: Exercise transcutaneous oxygen pressure measurement has good sensitivity and specificity to detect lower extremity arterial stenosis assessed by computed tomography angiography. Medicine (Baltimore). 95:e45222016. View Article : Google Scholar : PubMed/NCBI

44 

Mahé G, Ouedraogo N, Leftheriotis G, Vielle B, Picquet J and Abraham P: Exercise treadmill testing in patients with claudication, with and without diabetes. Diabet Med. 28:356–362. 2011.PubMed/NCBI

45 

Arsenault KA, McDonald J, Devereaux PJ, Thorlund K, Tittley JG and Whitlock RP: The use of transcutaneous oximetry to predict complications of chronic wound healing: A systematic review and meta-analysis. Wound Repair Regen. 19:657–663. 2011. View Article : Google Scholar : PubMed/NCBI

46 

Nishio H, Minakata K, Kawaguchi A, Kumagai M, Ikeda T, Shimizu A, Yokode M, Morita S and Sakata R: Transcutaneous oxygen pressure as a surrogate index of lower limb amputation. Int Angiol. 35:565–572. 2016.PubMed/NCBI

47 

Okamoto K, Oka M, Maesato K, Ikee R, Mano T, Moriya H, Ohtake T and Kobayashi S: Peripheral arterial occlusive disease is more prevalent in patients with hemodialysis: Comparison with the findings of multidetector-row computed tomography. Am J Kidney Dis. 48:269–276. 2006. View Article : Google Scholar : PubMed/NCBI

Related Articles

Journal Cover

April 2018
Volume 8 Issue 4

Print ISSN: 2049-9434
Online ISSN:2049-9442

Sign up for eToc alerts

Recommend to Library

Copy and paste a formatted citation
APA
Pan, X., Chen, G., Wu, P., Han, C., & Ho, J.K. (2018). Skin perfusion pressure as a predictor of ischemic wound healing potential (Review). Biomedical Reports, 8, 330-334. https://doi.org/10.3892/br.2018.1064
MLA
Pan, X., Chen, G., Wu, P., Han, C., Ho, J. K."Skin perfusion pressure as a predictor of ischemic wound healing potential (Review)". Biomedical Reports 8.4 (2018): 330-334.
Chicago
Pan, X., Chen, G., Wu, P., Han, C., Ho, J. K."Skin perfusion pressure as a predictor of ischemic wound healing potential (Review)". Biomedical Reports 8, no. 4 (2018): 330-334. https://doi.org/10.3892/br.2018.1064