Abbreviations
CLTI, Chronic limb-threatening ischemia
CVI, Chronic venous insufficiency
ICG, Indocyanine green
SPP, Skin perfusion pressure
In the landscape of modern medical challenges, vascular wound management occupies a critical intersection, where the intricacies of lifestyle diseases meet the advancements in medical devices. The growing prevalence and severity of arterial and venous wounds, primarily due to chronic limb-threatening ischemia (CLTI) and chronic venous insufficiency (CVI), present a significant global healthcare concern. This increase is largely driven by the aging society and lifestyle factors such as the global trend of obesity,1 tobacco use, and the growing prevalence of type 2 diabetes.
Advanced vascular wounds are particularly resistant to healing even with treatments such as percutaneous angioplasty and surgical interventions, and they embody a range of medical complexities. These wounds often lead to significant tissue loss, muscle degeneration, and nerve damage, adversely affecting limb function and overall life quality.2 In addition, their complexity necessitates a comprehensive, aggressive approach to wound management, emphasizing the need to address ongoing ischemia, uncontrolled infection, and biomechanical stresses. Moreover, the compounded challenges posed by diabetes and immune disorders make managing these wounds even more difficult.
In a landmark effort, experts from cardiology, plastic surgery, and cardiovascular surgery have come together to establish a consensus on advanced vascular wound management, underscoring the complexity and critical nature of interdisciplinary cooperation in this domain.3 This consensus is characterized by its adoption of perfusion-guided treatment strategies and meticulous follow-up protocols, aiming to significantly advance the standards of wound care. Central to the consensus is the P-A-O-D framework, a comprehensive and systematic approach encapsulating four pivotal elements: [P] Perfusion Restoration, addressing the crucial aspect of vascular insufficiencies in initiating the healing process; [A] Antimicrobials, strategically employed to manage and mitigate the risk of infection; [O] Optimization of Wound Healing, which involves the application of state-of-the-art therapeutic techniques to maximize healing efficacy; and [D] Device Utilization, integrating innovative medical devices into the wound care regimen. This framework not only represents a synthesis of multidisciplinary expertise but also sets a new benchmark in the field, emphasizing the critical role of integrated, advanced strategies in enhancing patient outcomes in vascular wound management.
Delving deeper into the complexities of vascular wound management reveals that these wounds reflect broader health and lifestyle issues. Thus, managing them extends beyond conventional medical treatment, requiring a holistic strategy that includes patient education, lifestyle modification, and continuous care, with the aim of enhancing clinical outcomes and improving the quality of life for patients.
THE IMPERATIVE FOR ADVANCED VASCULAR WOUND CENTERS
The medical community is currently facing increases in the complexity of vascular wounds, a challenge that necessitates the establishment of specialized Advanced Vascular Wound Centers. Far from being just facilities, these centers represent the pinnacle of integrated care, epitomizing multidisciplinary collaboration essential in addressing the complexities of vascular wounds.4 The necessity for these centers is heightened by the growing prevalence of CLTI and CVI, which surpass the capabilities of conventional wound care.
These centers address the intricate challenges in vascular wound management, such as persistent ischemia, uncontrolled infections, and the complexities of diabetes-related wounds. They foster an environment where specialists — cardiologists, vascular surgeons, endocrinologists, and plastic surgeons — work together to provide comprehensive care. This collaborative approach extends beyond treating the wound to understanding and addressing its underlying causes, ensuring personalized care through advanced diagnostic tools such as ankle-brachial index, indocyanine green (ICG), and skin perfusion pressure (SPP) assessments.
Moreover, these centers serve as innovation and education hubs, advancing our understanding of vascular wounds through research and clinical trials. They play a crucial role in educating healthcare professionals and patients about best practices in wound management, emphasizing early intervention and ongoing care.
TEAM-BASED APPROACH: A KEY TO SUCCESS IN VASCULAR WOUND CARE
Managing advanced vascular wounds requires a nuanced approach that goes beyond conventional medical practices, as highlighted in the manuscript. This complexity necessitates a team-based strategy to improve patient outcomes in vascular wound management (Figure 1). Such a multidisciplinary team, composed of cardiologists, vascular surgeons, plastic surgeons, endocrinologists, rehabilitation specialists, specialized nurses, and wound care experts, operates under the principles of collaboration and comprehensive care.5,6 Each professional contributes unique skills and perspectives, fostering a synergistic environment optimized for patient care. The approach is particularly effective in addressing the multifaceted nature of vascular wounds, which often involve vascular pathology intertwined with complex comorbidities such as diabetes and peripheral arterial disease.
Figure 1.
The Advanced Vascular Wound Center. A Paradigm of Integrated Care and Health Equity. At the core of the center’s philosophy is the patient-centric approach, symbolized by the central pentagon, emphasizing continuous follow-up, medical quality, and tackling challenging diseases. The encompassing triangular segments represent the innovative methodologies — personalized medicine, advanced medical devices, and molecular research — essential for superior care delivery. The adjacent illustrations personify the interdisciplinary expertise, with a plastic surgeon indicative of reconstructive excellence and a cardiologist/vascular surgeon embodying comprehensive cardiovascular care. This model illustrates the center’s dedication to bridging healthcare disparities through specialized and equitable treatment avenues, thus contributing to the broader objectives of public health.
Regular multidisciplinary meetings are crucial within this framework, providing a forum for discussing patient progress, exchanging insights, and developing comprehensive treatment strategies. Leadership plays a critical role in coordinating these efforts, ensuring patient-centered and evidence-based care. In addition, this team-based approach accelerates the integration of research findings into clinical practice, allowing for rapid communication of novel research within the team and its application in patient care. This process not only brings new treatments from the laboratory to the bedside more quickly but also aids in creating personalized treatment plans, increasingly vital in modern medicine.7
The team structure also includes mechanisms for continuous improvement. Performance reviews and feedback sessions are integral to this, ensuring consistent advancement and adaptation to evolving patient needs and advances in medical care. This reflective practice is essential for maintaining high standards of care and fostering a learning and growth environment.
In conclusion, the team-based approach in advanced vascular wound management is a model of healthcare excellence. It emphasizes the importance of collaboration, communication, and comprehensive care in improving patient outcomes, serving as a beacon for other medical areas by demonstrating the transformative power of teamwork in healthcare.
PERFUSION EVALUATION: THE CORNERSTONE OF EFFECTIVE TREATMENT
Perfusion evaluation is a key element in effective vascular wound management, as discussed in the manuscript. This assessment is critical in diagnosing and managing vascular wounds, where maintaining adequate blood flow is essential. Techniques such as SPP and ICG play a vital role in these evaluations, guiding treatment decisions and monitoring intervention efficacy.
SPP is a non-invasive measure of local blood flow which offers crucial insights into the vascular status of a wound and aids in assessing wound healing potential and the need for revascularization. ICG is used with near-infrared fluorescence imaging, and it provides a dynamic, real-time perfusion assessment, enabling microcirculation blood flow visualization. This helps to identify areas of ischemia and guide targeted interventions.8
The manuscript details the integration of these diagnostic tools into the multidisciplinary team approach. In a collaborative setting, these assessments inform tailored treatment strategies, aligning care with each patient’s specific perfusion status. This personalized approach is especially beneficial for patients with complex comorbidities such as diabetes, where perfusion issues are often compounded by systemic complications. Continuous perfusion monitoring is pivotal in vascular wound management, as it allows for the timely detection of changes in vascular status, facilitating prompt treatment plan adjustments. This proactive monitoring approach is crucial in preventing wound progression, reducing severe outcomes such as amputation, and increasing the likelihood of successful wound closure.9
In summary, evaluating perfusion is foundational in vascular wound management, influencing treatment strategies and outcomes. The integration of SPP and ICG assessments into a patient-centric, multidisciplinary approach exemplifies the advancement of vascular wound care, and underscores the importance of precision and personalization in modern medical practice. This approach ensures that interventions are not just timely but also tailored to each patient’s unique needs.10
REHABILITATION: AN INTEGRAL COMPONENT OF VASCULAR WOUND MANAGEMENT
The role of rehabilitation in managing vascular wounds is multifaceted and integral, extending beyond mere physical recovery.11 It is a comprehensive approach that aims to enhance overall patient outcomes, facilitate functional restoration, and improve long-term management of these wounds. Rehabilitation services are central to the holistic care of patients with vascular wounds, addressing not just the wound but also its underlying causes and the patient’s overall functional status, particularly in cases complicated by comorbidities such as diabetes or peripheral arterial disease.12
Critical to rehabilitation is the management of functional impairment and mobility restrictions.13 Vascular wounds, especially those in the lower extremities, can severely impact daily activities. Tailored rehabilitation programs, including physical therapy and exercise, play a vital role in restoring mobility, enhancing blood flow to the affected area, promoting healing, and reducing the risk of recurrence.14
Rehabilitation services are also key to educating patients about wound care, lifestyle modifications, and managing comorbid conditions. This education empowers patients, enabling them to actively participate in their recovery and prevent future complications. Rehabilitation also addresses the psychosocial challenges of living with a vascular wound, supporting patients in coping with the stress and improving their quality of life.
Taken together, rehabilitation in vascular wound management bridges the gap between medical treatment and full recovery, addressing physical, educational, and psychosocial needs. This holistic approach not only improves short-term outcomes but also significantly contributes to long-term health and well-being.
LONG-TERM MANAGEMENT AND FOLLOW-UP: ENSURING CONTINUED CARE
Vascular wound management requires a sustained and vigilant approach beyond the initial treatment phase. Long-term management and follow-up are essential to prevent recurrence, ensure comprehensive patient care, and enhance overall outcomes. This phase ensures the durability of treatment benefits and addresses the evolving needs of patients over time.
The ongoing evaluation of perfusion is a key aspect of long-term management. Continuous vascular status monitoring using assessments such as SPP and ICG imaging is critical for the early detection of wound deterioration and to allow for prompt adjustments in treatment strategy. This is especially important for patients with comorbid conditions such as diabetes, where vascular health can fluctuate due to systemic factors.15
Regular follow-up appointments are the cornerstone of long-term management. These visits allow healthcare professionals to assess healing progress, manage complications, and reinforce patient education on wound care and lifestyle changes. They also allow healthcare professionals to reassess the patient’s overall health and adjust medical therapies as necessary.16
The role of a multidisciplinary team remains significant in this phase, ensuring a comprehensive, adaptable approach to care. This team-based strategy ensures consistent and coordinated interventions over the long term. Engaging patients in their care through self-monitoring and adherence to therapies is also crucial for successful outcomes. Educating patients about signs of wound deterioration and the importance of regular follow-up visits can empower them to be vigilant and proactive in their health management.
Overall, long-term management and follow-up are critical in the continuum of care for vascular wound patients. This phase goes beyond preventing recurrence and focuses on maintaining a high-quality, sustained life, further highlighting the importance of continuous care and monitoring in the holistic management of these wounds.
DECLARATION OF CONFLICT OF INTEREST
All authors have declared no conflicts of interest.
Acknowledgments
C.Y.W. acknowledges financial support from the National Health Research Institute (Grant Nos. CS-112-PP-14), National Health Research Institutes and Central Government S&T grant (110-0324-01-25-01/111-0324-01-27-12), National Science Council (Grant Nos. 112-2314-B-182-036-MY3), and Chang Gung Memorial Hospital (Grant Nos. CMRPG3N0671, CMRPG3L1152, CMRPG3L0872, CORPG3N0031).
DISCLOSURE STATEMENT
None of the authors have any disclosures.
REFERENCES
- 1.Wang CY. Circadian rhythm, exercise, and heart. Acta Cardiol Sin. 2017;33:539–541. doi: 10.6515/ACS20170604A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Lepäntalo M, Tukiainen E. Combined vascular reconstruction and microvascular muscle flap transfer for salvage of ischaemic legs with major tissue loss and wound complications. Eur J Vasc Endovasc Surg. 1996;12:65–69. doi: 10.1016/s1078-5884(96)80277-2. [DOI] [PubMed] [Google Scholar]
- 3.Wu Y, Wang CY, Cheng NC, et al. 2024 TSOC/TSPS Joint Consensus: strategies for advanced vascular wound management in arterial and venous diseases. Acta Cardiol Sin. 2024;40:1–44. doi: 10.6515/ACS.202401_40(1).20231220A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Salutini E, Brocco E, Da Ros R, et al. The complexity of diabetic foot management: from common care to best practice. The Italian expert opinion by Delphi survey. Int J Low Extrem Wounds. 2020;19:34–43. doi: 10.1177/1534734619890814. [DOI] [PubMed] [Google Scholar]
- 5.Kim PJ, Evans KK, Steinberg JS, et al. Critical elements to building an effective wound care center. J Vasc Surg. 2013;57:1703–1709. doi: 10.1016/j.jvs.2012.11.112. [DOI] [PubMed] [Google Scholar]
- 6.Moore Z, Butcher G, Corbett LQ, et al. Exploring the concept of a team approach to wound care: managing wounds as a team. J Wound Care. 2014;23 Suppl 5b:S1–S38. doi: 10.12968/jowc.2014.23.Sup5b.S1. [DOI] [PubMed] [Google Scholar]
- 7.Parker C, Francis A, Robson L, Jones A. Building wound care capability: the development of an education and training directory for health professionals in Australia. Wound Pract Res. 2022;30 [Google Scholar]
- 8.Zhu G, Gao B, Fan J, et al. ICG-mediated fluorescence-assisted debridement to promote wound healing. PLoS One. 2023;18:e0291508. doi: 10.1371/journal.pone.0291508. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lam D, Rindani R, Leslie S, et al. Value of indocyanine green angiography to guide wound management and prevent necrosis in a robotic surgical procedure. J Endourol Case Rep. 2020;6:156–159. doi: 10.1089/cren.2019.0149. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Lee JK, Hsieh IC, Su CH, et al. Referral, diagnosis, and pharmacological management of peripheral artery disease: perspectives from Taiwan. Acta Cardiol Sin. 2023;39:97–108. doi: 10.6515/ACS.202301_39(1).20220815A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kourek C, Dimopoulos S, Alshamari M, et al. A cardiac rehabilitation program increases the acute response of endothelial progenitor cells to maximal exercise in heart failure patients. Acta Cardiol Sin. 2022;38:516–520. doi: 10.6515/ACS.202207_38(4).20220221B. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Lu CR, Lu SY, Lin SY, et al. Protective effects of statins on limb and cardiovascular outcomes in patients with peripheral artery disease and end-stage renal disease. Acta Cardiol Sin. 2023;39:755–764. doi: 10.6515/ACS.202309_39(5).20230118A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chiu YW, Huang WC. Cardiopulmonary exercise test and rehabilitation for pulmonary hypertension patients. Acta Cardiol Sin. 2022;38:663–666. doi: 10.6515/ACS.202211_38(6).20220603A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Salisbury DL, Brown R, Elgersma K, et al. Clinical effectiveness of a supervised exercise therapy program for treatment of peripheral artery disease: a translational study. J Cardiopulm Rehabil Prev. 2023;43:361–367. doi: 10.1097/HCR.0000000000000790. [DOI] [PubMed] [Google Scholar]
- 15.Fichter AM, von Bomhard A, Grill FD, et al. Preoperative peroneal artery perforator mapping using indocyanine green angiography: a prospective clinical trial. Plast Reconstr Surg. 2022;149:1193e–1197e. doi: 10.1097/PRS.0000000000009131. [DOI] [PubMed] [Google Scholar]
- 16.Golledge J, Velu R, Quigley F, et al. Cohort study examining the prevalence and relationship with outcome of standard modifiable risk factors in patients with peripheral artery occlusive and aneurysmal disease. Eur J Vasc Endovasc Surg. 2022;63:305–313. doi: 10.1016/j.ejvs.2021.10.039. [DOI] [PubMed] [Google Scholar]