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## Complete Summary

#### GUIDELINE TITLE

Guideline for management of wounds in patients with lower-extremity
arterial disease.

#### BIBLIOGRAPHIC SOURCE(S)

Bonham PA, Flemister BG. Guideline for management of wounds in patients
with lower-extremity arterial disease. Mount Laurel (NJ): Wound, Ostomy
and Continence Nurses Society (WOCN); 2008. 63 p. (WOCN clinical
practice guideline series; no. 1). \[268 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Wound Ostomy and Continence
Nurses Society (WOCN). Guideline for management of wounds in patients
with lower-extremity arterial disease. Glenview (IL): Wound Ostomy and
Continence Nurses Society (WOCN); 2002 Jun. 44 p. (WOCN clinical
practice guideline series; no. 1).

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Lower-extremity arterial disease (LEAD)

-   Lower-extremity ischemic wounds

-   Limb ischemia

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Dermatology\
Endocrinology\
Family Practice\
Internal Medicine\
Nursing\
Orthopedic Surgery\
Physical Medicine and Rehabilitation\
Podiatry\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Health Care Providers\
Nurses\
Physical Therapists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To support clinical practice by providing consistent research-based
information with the goal of improved, cost-effective patient outcomes
as well as to stimulate increased wound research

#### TARGET POPULATION

Patients with lower extremity arterial disease (LEAD) and
lower-extremity wounds

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment**

1.  Assessment of causative and contributive factors and significant
    signs and symptoms to differentiate types of lower-extremity ulcers

2.  Review of health history, including risk factors for lower extremity
    arterial disease (LEAD), wound history, pain history, history of
    prescribed and self-prescribed medications

3.  Review of pertinent labs, including cholesterol and triglycerides,
    lipoproteins, and homocysteine, to identify risk markers for lower
    extremity arterial disease

4.  Comprehensive lower-extremity examination, including perfusion
    status, pedal pulses, ankle brachial index (ABI), ankle pressure,
    toe pressure and toe brachial index (TBI), assessments for critical
    limb ischemia and ischemic skin changes, wound characteristics

**Management/Treatment**

1.  Care guided by a clinical wound expert

2.  Wound management (cleaning wounds, debridement, dressing, proper use
    of antiseptics and topical antibiotics)

3.  Monitoring for signs of infection

4.  Nutrition support

5.  Pain management

6.  Management of edema

7.  Referral for further evaluation

8.  Medications, including statins, cilostazol, aspirin, and clopidogrel

9.  Surgical options

10. Adjunctive therapies

11. Patient education

**Note**: The following measures were considered but have not been shown
to improve clinical outcomes in LEAD:

-   Nutritional measures: vitamin E, garlic and/or fish oil; L-arginine,
    chelation therapy

-   Prostaglandins (PGE-1 and PGE-2) and pentoxyphylline for use in
    treatment of underlying disease process or resulting wounds

-   Skin grafts for wounds in unreconstructed arterial disease

#### MAJOR OUTCOMES CONSIDERED

-   Wound healing

-   Complications of lower-extremity arterial disease (LEAD)

-   Treatment failure

-   Functional status

-   Quality of life

-   Limb loss

-   Mortality rates

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The primary authors of this guideline independently conducted searches
of Medline, CINAHL and Cochrane Library databases for studies published
in English from January 2002 through April 2007. The following medical
subject headings (MESH) were used to search for each specific question
related to lower extremity arterial disease (LEAD): arterial disease,
arterial insufficiency, peripheral arterial disease, peripheral vascular
disease, lower-extremity arterial disease, peripheral arterial occlusive
disease, lower-extremity ischemic wounds and ulcers and critical limb
ischemia. The search targeted meta-analyses, randomized controlled
trials (RCTs), prospective clinical trials, retrospective studies and
systematic reviews. Reference lists of selected articles were also
reviewed to identify relevant studies to include.

#### NUMBER OF SOURCE DOCUMENTS

More than 325 articles were identified and reviewed for this guideline.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Rating of Research Evidence**

**Level I**: A randomized controlled trial (RCT) demonstrating a
statistically significant difference in at least one important outcome
defined by *p* \< .05. Level I trials can conclude the difference is not
statistically significant if the sample size is adequate to exclude a 25
percent difference among study arms with 80 percent power.

**Level II**: A RCT not meeting Level I criteria.

**Level III**: A non-randomized controlled trial with contemporaneous
controls selected by some systematic method. A control might have been
selected due to its perceived suitability as a treatment option for an
individual patient.

**Level IV**: A before-and-after study or a case series of at least 10
patients using historical controls or controls drawn from other studies.

**Level V**: A case series of at least 10 patients with no controls.

**Level VI**: A case report of fewer than 10 patients.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Two primary reviewers read and summarized selected articles. Each study
was assigned a level of evidence rating of Level I to Level VI.

To classify the strength of the evidence in this guideline, a
level-of-evidence rating (Level A, B or C) has been assigned to specific
recommendations. The rating refers to the strength of the evidence for a
recommendation and does not relate to the importance of the
recommendation. The rating system was adapted from the rating systems
described by Sackett (1989), Cook,Guyatt, Laupacis and Sackett (1994)
the Agency for Health Care Policy and Research (AHCPR---now called AHRQ)
(1992, 1994) and the American College of Cardiology Foundation-American
Heart Association (2006). Where a level-of-evidence rating is not
included, the information or recommendation presented represents a
consensus of the panel members.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Wound, Ostomy and Continence Nurses (WOCN) Society developed this
evidence-based guideline using the following process: (a) A panel of
nurses from the WOCN membership, representing a wide range of experience
and clinical practice backgrounds, convened to plan the guideline
format; (b) a topical outline was designed and specific questions about
lower-extremity arterial disease (LEAD) were proposed to guide the
search of the literature for evidence; and (c) studies reporting primary
data relevant to LEAD and specific therapies or diagnostic modalities
were included in the review. The panel developed 21 questions related to
screening and diagnosis, healing and treatments, infection, topical
wound treatments, and management of patients with LEAD to guide the
evidence-based review of the literature.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Level-of-Evidence Rating for Guideline Recommendations\***

**Level A**: Two or more supporting RCTs of at least 10 humans with
lower-extremity arterial disease (LEAD) (at Levels I or II), a
meta-analysis of RCTs or a Cochrane Systematic Review of RCTs.

**Level B**: One or more supporting controlled trials of at least 10
humans with LEAD or two or more supporting non-randomized trials of at
least 10 humans with LEAD (at Level III).

**Level C**: Two supporting case series of at least 10 humans with LEAD
or expert opinion.

\*The rating refers to the strength of the evidence for a recommendation
and does not relate to the importance of the recommendation.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

After the two primary authors reviewed the selected studies, the written
summary of the evidence was presented to all committee members for
review, discussion, and clarification. A series of conference calls was
conducted during 2006 and 2007, and the guideline was finalized
incorporating evidence from the studies.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

A level of evidence rating (**A-C**) has been assigned specific
recommendations and is defined at the end of the \"Major
Recommendations\" field. Citations in support of individual
recommendations are identified in the original guideline document.

**Assessment of Patients with Wounds and Lower Extremity Arterial
Disease (LEAD)**

1.  Prior to treatment, assess causative and contributive factors and
    significant signs and symptoms to differentiate types of
    lower-extremity ulcers, which require varying treatments. (See
    \"Algorithm: Differential Assessment\" in the appendix of the
    original guideline document.)

2.  Review health history to address risk factors for LEAD: wound
    history: pain history and history of prescribed/self-prescribed
    medications.

    a.  Assess pain characteristics: onset, duration, location,
        precipitating/alleviating factors and presence/absence of
        intermittent claudication.

    b.  Differentiate acute limb ischemia (rapid, sudden decrease in
        limb perfusion often associated with thrombosis) from critical
        limb ischemia that is chronic and progressive in nature due to
        atherosclerosis.

> ***Level of evidence = C***

3.  Review pertinent labs to identify risk markers for LEAD:

    a.  Elevated total cholesterol and triglycerides and reduced high
        density cholesterol (HDL). ***Level of evidence = B***

    b.  Elevated lipoprotein. ***Level of evidence = B***

    c.  Elevated homocysteine levels. ***Level of evidence = B***

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4.  Conduct a comprehensive lower-extremity examination:

    a.  Assess functional ability

    b.  Determine perfusion status by assessing skin temperature,
        capillary refill, venous refill, color changes, and
        paresthesias.

    c.  Determine presence or absence of pedal pulses. Palpate both
        dorsalis pedis and posterior tibial pulses of each lower
        extremity. Presence of palpable pulses does not rule out LEAD.

> ***Level of evidence = B***

d.  Ausculate femoral/popliteal arteries for bruits. ***Level of
    evidence = C***

e.  Observe for signs of neuropathy, which can cause impaired muscle
    function. ***Level of evidence = B***

f.  Determine neurosensory status by screening both feet for loss of
    protective sensation with a monofilament, tuning fork and percussion
    hammer.

g.  Measure ankle brachial index (ABI) to assess arterial blood flow in
    the lower extremities and determine level of ischemia: Normal \>1.0;
    LEAD [\<]{.underline}0.9, borderline is \<0.6 to 0.8, severe
    ischemia is \< 0.5 and critical ischemia \<0.4. The ABI can be
    elevated (\>1.3) in individuals with diabetes, renal failure or
    arthritis who have non-compressible vessels due to calcification of
    the ankle arteries. ***Level of evidence = B***

h.  Recheck the ABI periodically (every 3 months) for patients with
    non-healing lower extremity wounds. ***Level of evidence = C***

i.  Measure toe pressures (TP) to determine a toe brachial index (TBI)
    for patients whose ABI is \>1.3. A systolic TP \<30 mmHg (\< 50 mmHg
    in persons with diabetes) or TBI \< 0.6 indicates LEAD. ***Level of
    evidence = B***

j.  Assess tissue perfusion with transcutaneous oxygen measurement
    (TcPO~2~) if an ulcer is not healing and the ABI is \<0.9, TP \<30
    mmHg, or if unable to perform ABI or TP because of incompressible
    arteries at the ankle, or the patient has had an amputation. A
    TcPO~2~ \<40 mmHg is considered hypoxic and is associated with
    impaired wound healing. ***Level of evidence = A***

k.  Consider other noninvasive tests if ABI, toe pressure, TBI, or
    TcPO~2~ are inconclusive or cannot be performed.

l.  Consider use of magnetic resonance angiography, ***Level of evidence
    = A***, or computed tomographic angiography to select surgical or
    endovascular candidates. ***Level of evidence = B***.

m.  Consider use of invasive studies such as contrast catheter
    angiography to definitively determine the anatomic location of LEAD
    when surgery is planned. ***Level of evidence = B***

n.  Assess all patients with ischemic rest pain or pedal wounds for
    indicators of critical limb ischemia: ankle systolic pressure \<50
    mmHg, toe systolic pressure \<30 mmHg or TcPO~2~ \<30 mmHg. ***Level
    of evidence = C***

o.  Assess the lower extremities for ischemic skin changes: purpura,
    atrophy of the skin, subcutaneous tissue and muscle; shiny and taut
    skin, hair loss and/or dystrophic nails.

p.  Determine wound characteristics: location, pain, shape, size, color
    of wound base and type tissue, wound edges, periwound skin, exudate
    and presence/absence of odor or necrosis (or both).

q.  Assess for wound complications: cellulitis, gangrene or
    osteomyelitis.

r.  Refer wounds that are atypical in appearance or unresponsive to 2 to
    4 weeks of appropriate therapy for further vascular evaluation or
    biopsy.

**Interventions for Patients with Wounds and LEAD**

1.  Recommend patients with wounds and LEAD seek care guided by a
    clinical wound expert. ***Level of evidence = C***

2.  Relate wound treatments to adequacy of perfusion status.

3.  Cleanse wounds with non-cytotoxic cleansers

**Debridement**

4.  Do not debride stable, black eschars until perfusion status is
    determined. Debridement may be contraindicated in LEAD wounds.
    ***Level of evidence = C***

5.  Consider revascularization and surgical removal of necrotic tissue
    from an infected wound on an ischemic leg, which is the treatment of
    choice for limb salvage. ***Level of evidence = C***

6.  Closely monitor autolytic or enzymatic debridement if used for open,
    draining LEAD wounds with necrotic tissue. ***Level of evidence =
    C***

**Dressings**

7.  Choose dressings for LEAD wounds permitting frequent visualization
    and inspection of the wound. ***Level of evidence = C***

8.  Conduct a carefully monitored trial of moist dressings for LEAD open
    and draining wounds with soft slough/necrotic material or exposed
    bones or tendons. ***Level of evidence = C***

9.  Maintain dry, stable eschar in non-infected ischemic wounds.
    ***Level of evidence = C***

**Antibiotics**

10. Do not rely on topical antibiotics to treat infected, ischemic
    wounds. ***Level of evidence = C***

11. Institute systemic antibiotics promptly in patients with critical
    limb ischemia and evidence of limb infection or cellulitis and/or
    infected wounds. ***Level of evidence = C***

**Infection**

12. Monitor LEAD wounds closely for signs/symptoms of infection, which
    can be subtle because of reduced blood flow. ***Level of evidence =
    C***

13. Refer infected LEAD wounds, which are limb threatening, for
    immediate evaluation, culture-guided antibiotics therapy, assessment
    of perfusion status, and/or need for surgical intervention. ***Level
    of evidence = C***

14. Use tissue biopsy, considered the gold standard, to confirm
    diagnosis of infection. Limited studies (not specific to LEAD) have
    demonstrated that noninvasive, quantitative swab cultures are a
    reasonable alternative to biopsies in general clinical practice
    settings. ***Level of evidence = B***

**Nutrition**

15. Consider niacin or vitamin B-6 dietary supplementation for patients
    with LEAD. Niacin (in oral dosages of 3,000 mg/d for up to 60 weeks
    in patients with LEAD) increases HDL-C and decreases triglycerides.
    ***Level of evidence = B***

16. Daily intake of vitamin B-6 may decrease risk of LEAD. ***Level of
    evidence = C***

17. Provide nutritional support with 2,000 or more calories
    preoperatively and postoperatively (if possible), which has
    benefited patients undergoing amputations. ***Level of evidence =
    C***

**Pain Management**

18. Institute a regular, exercise program for medically stable patients
    with intermittent claudication. Supervised exercise sessions, three
    times per week, of 30 to 60 minutes of treadmill or track walking to
    the point of pain, followed by rest, has increased pain-free walking
    and total walking distance. ***Level of evidence = A***

19. Recommend self-directed walking programs for those who are unwilling
    or unable to participate in supervised exercise programs. ***Level
    of evidence = A***

20. Refer patients with severe and intractable pain for surgical
    evaluation for reconstructable disease. ***Level of evidence = C***

21. Consider spinal cord stimulation (SCS) for patients with intractable
    pain and with limb ischemia who are unsuitable for reconstruction
    and whose foot TcPO~2~ is between 10 to 30 mmHg with an increase of
    more than 10 mmHg during a trial of SCS. ***Level of evidence = B***

**Management of Edema in Patients with Mixed Venous Disease and Moderate
Arterial Disease**

22. Use reduced compression (23 to 30 mmHg at the ankle) for patients
    with venous disease, wounds and edema who also have moderate
    arterial insufficiency (ABI \>0.5 to \<0.8). Sustained, high
    compression should not be used for patients with ABI \<0.5 mmHg.
    ***Level of evidence = C***

**Referral for Further Evaluation**

23. Refer patients for further evaluation with the following symptoms,
    conditions or assessment findings:

    -   Cellulitis, osteomyelitis, atypical ulcers, intractable pain

    -   Absence of both pedal and posterior tibial pulses

    -   An ABI \<0.9 plus any one of the following---an ulcer failing to
        improve within 2 to 4 weeks of appropriate therapy, severe
        ischemic pain and/or intermittent claudication

    -   Toe pressure \<30 mmHg

    -   Ankle pressure \<50 mmHg or ABI \<0.5

> ***Level of evidence = C***

24. Refer patients with ABI \<0.4 and/or gangrene for urgent vascular
    evaluation. ***Level of evidence = C***

**Medications**

25. Statins. Statin drugs improve ABI, leg function and reduce
    cardiovascular events. ***Level of evidence = A***

26. Cilostazol (100 mg, oral/twice a day). Cilostazol increases HDL,
    decreases triglycerides and lipoprotein levels and improves walking
    distances of patient with intermittent claudication. ***Level of
    evidence = A***

27. Aspirin (75 to 325 mg oral/day) is recommended for patients (not
    specific to LEAD) to prevent death and disability from stroke and
    myocardial infarction (MI). ***Level of evidence = C***

28. Clopidogrel (75 mg, oral/day) may be considered as an effective
    alternative to aspirin to decrease risk of stroke, myocardial
    infarction (MI) or vascular deaths for patients. ***Level of
    evidence = B***

**Surgical Options**

29. Carefully assess risks versus short-term and long-term benefits of
    bypass surgery or angioplasty. Short-term surgical benefits may not
    be sustained long term. ***Level of evidence = A***

30. Assess TcPO~2~ levels prior to amputation. Preoperative TcPO~2~
    levels greater than 20 mmHg are associated with successful healing
    after amputation. ***Level of evidence = A***

**Adjunctive Therapies**

31. Consider a trial of conservative therapies (topical therapy, low
    frequency ultrasound, electrotherapy \[high frequency, low pulsed\])
    for patients with borderline blood flow and wounds if they are free
    of limb threatening sepsis. ***Level of evidence = C***

32. Consider hyperbaric oxygen therapy for patients with non-healing,
    ischemic ulcers. ***Level of evidence = B***

33. Consider arterial flow augmentation (intermittent pneumatic
    compression) for individuals with intermittent claudication and
    limb-threatening arterial disease for whom vascular reconstruction
    is not feasible. ***Level of evidence = B***

**Patient Education**

34. Teach patients with LEAD about chronic disease management and
    measures to maintain intact skin and prevent trauma: control
    diabetes; hypertension and hyperlipidemia; adhere to medication
    regimen; use neutral or dependent position for legs; avoid chemical,
    thermal and mechanical trauma; have routine nail and foot care
    provided by a professional; wear proper-fitting shoes/footwear with
    socks or hose; provide pressure redistribution for heels, toes and
    other bony prominences and seek follow-up with a healthcare
    provider. ***Level of evidence = C***

35. Recommend tobacco cessation, which slows progression of
    atherosclerosis, decreases risk of cardiovascular events and death
    and may decrease the overall risk of LEAD after long-term cessation.
    ***Level of evidence = B***

36. Increase regular exercise and physical activity to improve symptoms
    of claudication. ***Level of evidence = A***

37. Encourage tobacco users to exercise: eight hours of exercise per
    week may negate some negative effects of tobacco use. ***Level of
    evidence = C***

**Definitions**:

**Rating of Evidence**

**Level I**: A randomized controlled trial (RCT) demonstrating a
statistically significant difference in at least one important outcome
defined by *p* \< .05. Level I trials can conclude the difference is not
statistically significant if the sample size is adequate to exclude a 25
percent difference among study arms with 80 percent power.

**Level II**: A RCT not meeting Level I criteria.

**Level III**: A non-randomized controlled trial with contemporaneous
controls selected by some systematic method. A control might have been
selected due to its perceived suitability as a treatment option for an
individual patient.

**Level IV**: A before-and-after study or a case series of at least 10
patients using historical controls or controls drawn from other studies.

**Level V**: A case series of at least 10 patients with no controls.

**Level VI**: A case report of fewer than 10 patients.

**Levels-of-Evidence Rating\***

**Level A**: Two or more supporting randomized controlled trials (RCTs)
of at least at least 10 humans with lower-extremity arterial disease
(LEAD) (at Levels I or II), a meta-analysis of RCTs or a Cochrane
Systematic Review of RCTs.

**Level B**: One or more supporting controlled trials of at least 10
humans with LEAD or two or more supporting non-randomized trials of at
least 10 humans with LEAD (at Level III).

**Level C**: Two supporting case series of at least 10 humans with LEAD
or expert opinion.

\*The rating refers to the strength of the evidence for a recommendation
and does not relate to the importance of the recommendation.

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the appendix of the original guideline
document for the differential assessment of wound etiology.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is identified and
graded for selected recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Identification of patients with lower-extremity arterial disease
    (LEAD) who are at risk for developing wounds

-   Identification of patients whose current wounds are caused or
    complicated by LEAD

-   Implementation of appropriate strategies and plans may:

    -   Reduce or eliminate known modifiable risk factors for LEAD

    -   Attain/maintain intact skin

    -   Reduce pain

    -   Prevent complications

    -   Promptly identify/manage complications

    -   Optimize potential for wound healing

    -   Promote limb preservation

    -   Improve functional status of symptomatic patients

    -   Involve patient/caregiver in self-management

#### POTENTIAL HARMS

-   The clinical usefulness of thienopyridines is limited by
    unacceptable side effects such as neutropenia due to bone-marrow
    suppression as well as thrombotic thrombocytopenia purpura.

-   The clinical usefulness of clopidogrel must be weighed against the
    side effects (risk of major bleeding) and high costs.

-   There is a potential for rebound mechanism after stopping
    clopidogrel.

-   Due to the high risk of hemorrhage or death, thrombolysis should be
    reserved for patients with limb-threatening ischemia.

-   Wounds treated with topical antibiotics may develop resistant
    organisms over time.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Surgical and endovascular treatments are not indicated for patients
    with decreased limb perfusion (ankle brachial index \< 0.4) in the
    absence of clinical symptoms of critical limb ischemia.

-   Mechanical, non-selective debridement is contraindicated in arterial
    wounds

-   Stable, black eschars should not be debrided until perfusion status
    is determined. Debridement may be contraindicated in lower-extremity
    arterial disease (LEAD) wounds.

-   Sustained, high compression should not be used for patients with ABI
    \< 0.5.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Bonham PA, Flemister BG. Guideline for management of wounds in patients
with lower-extremity arterial disease. Mount Laurel (NJ): Wound, Ostomy
and Continence Nurses Society (WOCN); 2008. 63 p. (WOCN clinical
practice guideline series; no. 1). \[268 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 Jun (revised 2008)

#### GUIDELINE DEVELOPER(S)

Wound, Ostomy, and Continence Nurses Society - Professional Association

#### SOURCE(S) OF FUNDING

No funding source has been identified.

#### GUIDELINE COMMITTEE

Wound, Ostomy, Continence Nurses (WOCN) Lower Extremity-Arterial Disease
Wound Guidelines Task Force

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Phyllis A. Bonham, PhD, RN, MSN, CWOCN, Wound Care
Education Program, College of Nursing, Medical University of South
Carolina, Charleston, SC; Bonny G. Flemister, MSN, RN, CWOCN, APRN, BC,
ANP, GNP, At Home Healthcare, Tyler, TX

*Task Force Members*: Margaret Goldberg, MSN, RN, CWOCN, Delray Wound
Treatment Center, Delray Beach, FL; Penny Ellen Crawford, MSN, CNS, FNP,
CWOCN, Sentara Wound Therapy Center, Norfolk, VA; Jan J. Johnson, MSN,
RN, CWOCN, FNP, Duke University Medical Center, Durham, NC; Myra F.
Varnado, BSN, RN, CDE, CWOCN, LSU Health Sciences Center, Independence,
LA

*Scribe*: Ronald Palmer, Fullerton, CA

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Individuals involved in developing clinical practice guidelines are
charged by the Wound, Ostomy and Continence Nurses (WOCN) Society to
develop objective, comprehensive and practical guidelines. To ensure the
integrity of the WOCN Society and the Clinical Practice Guideline
Program, prior to participating in any guideline activity, participants
submit a Disclosure Form to WOCN regarding any financial relationships
with commercial companies creating a conflict when the company\'s
products or services are related to the subject of the guideline.
Members of the guideline panel submitted a Disclosure Form, which was
reviewed by the WOCN Executive Director, who determined no conflict of
interest exists with any individual panel member.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Wound Ostomy and Continence
Nurses Society (WOCN). Guideline for management of wounds in patients
with lower-extremity arterial disease. Glenview (IL): Wound Ostomy and
Continence Nurses Society (WOCN); 2002 Jun. 44 p. (WOCN clinical
practice guideline series; no. 1).

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available for purchase for a nominal fee from the Wound
Ostomy and Continence Nurses Society (WOCN), 15000 Commerce Parkway,
Suite C, Mt. Laurel, NJ, 08054; Web site:
[www.wocn.org](http://www.wocn.org/). Orders can be placed thru the
[WOCN Web site](http://www.wocn.org/) or via telephone at (888)
224-9626.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on December 13, 2002. The
information was verified by the guideline developer on January 13, 2003.
This summary was updated by ECRI Institute on July 25, 2008. The updated
information was verified by the guideline developer on August 5, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Per the guideline
developer, the Wound, Ostomy and Continence Nurses (WOCN) Society
retains the copyright to the material in the *Guideline for Management
of Wounds in Patients with Lower-Extremity Arterial Disease*. Any
reproduction without consent is prohibited. Written requests to
reproduce any portion of the material contained within this guideline
may be directed to Pete Pomillo, MBA, Executive Director, Wound, Ostomy
and Continence Nurses Society national office: 15000 Commerce Parkway,
Suite C, Mt. Laurel, NJ, 08054.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008