Should I apply a tensor to a patient with a graft wound on the bottom of their foot, likely with a history of diabetes or peripheral arterial disease, without an available Ankle-Brachial Pressure Index (ABPI) measurement?

Should You Apply Tensor Bandaging Without ABPI?

Do not apply tensor (compression) bandaging to a graft wound on the foot without first obtaining an ABPI or alternative vascular assessment, as compression applied to an ischemic limb can cause tissue necrosis and graft failure. 1

Critical Safety Concern

Compression therapy is contraindicated in the presence of significant peripheral arterial disease (PAD), and a graft wound on the plantar foot raises immediate concern for underlying vascular compromise. 1 The risk of applying compression to an ischemic limb far outweighs any potential benefit, as it can critically reduce already compromised blood flow and lead to tissue death. 1

Immediate Assessment Required

Before any compression application, you must establish arterial perfusion status through one of these methods:

Primary Vascular Assessment Options

• Ankle-Brachial Index (ABPI/ABI): The ACC/AHA strongly recommends ABI measurement in all patients with nonhealing wounds, particularly those ≥65 years or ≥50 years with diabetes or smoking history. 1 An ABI <0.90 confirms PAD and is an absolute contraindication to compression. 1

• Toe-Brachial Index (TBI): If ABI cannot be obtained or is unreliable (>1.40 suggesting noncompressible vessels from arterial calcification, common in diabetes), the ACC/AHA recommends TBI measurement. 1 A TBI ≤0.70 indicates PAD and contraindicates compression. 1

• Toe Pressure: The IWGDF guidelines indicate that toe pressure <30 mmHg suggests critical limb-threatening ischemia requiring urgent vascular consultation, not compression therapy. 1

• Doppler Waveform Analysis: The ACC/AHA supports continuous-wave Doppler assessment to evaluate arterial flow. 1 Triphasic pedal Doppler waveforms largely exclude significant PAD, while monophasic or absent signals indicate arterial compromise. 1

Clinical Decision Algorithm

If vascular assessment shows:

• ABI ≥0.90 and <1.40 OR TBI ≥0.75 OR triphasic pedal Doppler waveforms: Compression may be considered safe from a vascular standpoint 1

• ABI <0.90 OR TBI <0.70 OR toe pressure <30 mmHg OR abnormal Doppler waveforms: Compression is contraindicated; refer urgently to vascular surgery 1, 2

• ABI >1.40 (noncompressible vessels): Obtain TBI or toe pressure before proceeding 1

• Unable to obtain any vascular measurement: Do not apply compression; obtain vascular consultation first 1, 2

High-Risk Patient Populations

This patient likely has diabetes or PAD given the presence of a graft wound on the plantar foot. The ESC guidelines emphasize that patients with chronic limb-threatening ischemia (CLTI) have very poor outcomes, and inappropriate compression can accelerate limb loss. 1 The IWGDF specifically warns that even palpable pulses may be present despite significant ischemia in diabetic patients with neuropathy. 1

Practical Next Steps

1. Contact the ordering provider immediately to clarify whether vascular assessment has been performed and to discuss the contraindication to compression without this information 2

2. Arrange urgent vascular assessment (ABI, TBI, or Doppler) before any compression application 1

3. If the patient has diabetes with nonhealing wounds, the ACC/AHA mandates ABI measurement as a Class I recommendation 1

4. Document clearly that compression was not applied pending vascular assessment due to safety concerns 1

Common Pitfall to Avoid

The most dangerous error is assuming adequate perfusion based on clinical examination alone. The IWGDF guidelines explicitly state that palpable pulses do not exclude significant ischemia, particularly in diabetic patients with neuropathy and arterial calcification. 1 Junior medical staff performing ABPI measurements without proper training have nearly 30% error rates, so ensure measurements are performed by trained personnel. 3