If an ulcer has not progressed despite optimal treatment and ankle brachial pressure index is less than 0.5 or the Doppler waveform is damped and either TcPo2 is less than 30 mmHg or toe pressure is less than 30 mmHg, then angiography should ideally be carried out. It is difficult to state when intervention should be carried out as this varies from patient to patient. However, the recommendations of the American Diabetes Association state that
further investigations should be started after 4 weeks with standard treatment.
Non-invasive procedures should be used first to examine the peripheral circulation and to detect areas of stenosis and occlusion. Transfemoral angiography with angioplasty can then be used as a definitive localized invasive procedure.
Angiography can be carried out by an examination which combines the features of Doppler waveform analysis with ultrasound imaging to produce a picture of arterial flow dynamics and morphology.
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