What is the best management approach for a patient with severe peripheral arterial disease (PAD), an Ankle-Brachial Index (ABI) of less than 0.4, and a mixed arterial and venous ulcer, who is also undergoing treatment for venous disease?

Management of Severe PAD with ABI <0.4 and Mixed Arterial-Venous Ulcer

This patient requires urgent vascular team evaluation and revascularization as soon as possible, as an ABI <0.4 indicates severe arterial obstruction representing chronic limb-threatening ischemia (CLTI), which mandates immediate intervention to prevent limb loss. 1

Immediate Priority: Urgent Revascularization

Your patient meets criteria for CLTI with severe ischemia (ABI <0.4 indicates severe arterial obstruction per standard classification) 1. The most recent 2024 ESC guidelines are unequivocal: in CLTI patients, revascularization must be performed as soon as possible 1. This is a Class I recommendation with the highest level of evidence.

Critical Management Steps:

1. Urgent Vascular Team Referral

• This patient requires immediate evaluation by a multidisciplinary vascular team including vascular surgery, interventional specialists, and wound care experts 1
• Early recognition and referral are specifically recommended for limb salvage 1
• The team should include infectious disease consultation if infection is present 1

2. Revascularization Strategy

The choice between endovascular and surgical approaches depends on several factors 1:

• Endovascular therapy should be considered first-line, especially given the mixed ulcer presentation and likely need for multilevel intervention 1
• If the patient has good autologous veins (great saphenous vein) and low surgical risk, infra-inguinal bypass may be considered 1
• In multilevel vascular disease, eliminate inflow obstructions when treating downstream lesions 1
• The 2024 ESC guidelines recommend using autologous veins as the preferred conduit for infra-inguinal bypass surgery when surgical revascularization is chosen 1

3. Critical Contraindication: Compression Therapy

With ABI <0.4, compression therapy for the venous component is absolutely contraindicated until arterial perfusion is restored 1. Standard venous ulcer treatment cannot proceed safely in the presence of severe arterial disease. The arterial insufficiency must be corrected first.

Concurrent Medical Management

While arranging urgent revascularization 1:

Wound Care:

• Immediate proper wound care with offloading mechanical tissue stress to allow healing 1
• Frequent debridement as needed 1
• Treatment of any concomitant infection 1
• Do NOT initiate lower-limb exercise training - this is contraindicated in CLTI patients with wounds 1

Antithrombotic Therapy:

• Consider combination rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily for high ischemic risk PAD patients with non-high bleeding risk 1
• This combination should be considered following lower-limb revascularization 1

Cardiovascular Risk Factor Management:

• Aggressive glycemic control if diabetic - particularly important for improved limb-related outcomes and lower amputation rates 1
• Lipid management, blood pressure control, and smoking cessation 1

Post-Revascularization Management

Only after successful revascularization can you address the venous component 1:

• Reassess ABI to confirm adequate arterial perfusion
• Gradually introduce compression therapy if ABI improves to >0.5-0.6 (though specific thresholds vary)
• Continue multidisciplinary wound care with adapted footwear 1
• Negative-pressure wound therapy may be helpful for wound healing after revascularization 1

Critical Pitfalls to Avoid

• Never apply compression therapy with ABI <0.4 - this will worsen tissue ischemia and accelerate limb loss
• Do not delay revascularization - the 2024 guidelines emphasize "as soon as possible" for a reason; delays increase amputation risk 1
• Do not treat this as primarily a venous ulcer - the severe arterial component (ABI <0.4) is the immediate threat to limb viability 1
• Avoid prescribing exercise training until after revascularization and wound healing 1

Prognosis Considerations

Without revascularization, limb salvage rates are approximately 50% at 1 year 1. After successful revascularization, limb salvage rates improve to 80-85% with ulcer healing in >60% at 12 months 1. The presence of both arterial and venous disease increases complexity, but the arterial component must be addressed first to prevent limb loss.