Transcutaneous Oxygen Tension in Imminent Foot Gangrene

Transcutaneous oxygen tension at 44C and maximal isotope clearance (⁹⁹ m Tcpertechnetate + histramine) just proximal to the 1st toe and systolic toe blood pressure (strain gauge) were studied on a tilt table in patients with various degrees of obstructive arteriosclerotic disease. In legs with moderate obstruction, the oxygen tension reached zero at a toe systolic blood pressure of 5–10 mmHg (tilt toe up) and reached arterial oxygen tension at about 50 to 70 mmHg (tilt toe down). In legs with severe arterial obstruction and ischaemic rest pain, oxygen tension rose from zero not before systolic toe blood pressure reached 20–50 mmHg. Significant isotope clearance was seen at pressures below the limits just mentioned for both types of patients.
This phenomenon here seen of a perfusion without oxygen supply is explained by a gas leak (rendered significant because of the slow flow rate) from the arterioles into the tissue sink and counter current gas shunting. The hypoxia in spite of a positive perfusion pressure up to 50 mmHg explains our experience that ischaemic ulcers in feet with such low pressures never heal.     

The ankle/arm systolic blood pressure ratio as a screening test for arterial insufficiency in the lower limb

Doppler-derived ankle/arm systolic blood pressure ratios were measured in 424 patients with ischaemic arterial disease of the lower limbs and in 52 controls. 90 of the patients were diabetic. The value of this simple test in screening for arterial insufficiency was evaluated retrospectively. The results were reproducible the coefficient of variation being about 10%. In most patients a test performed at rest was sufficient to detect arterial insufficiency. However, in some milder cases a stress test was needed to distinguish them from subjects without arterial insufficiency. In some patients with advanced diabetes mellitus false high pressure readings were recorded as a result of vessel wall stiffness. However, only one patient with mild diabetes had a false normal pressure ratio. In patients with distal gangrene diabetes mellitus caused erroneously high pressure ratios.     

Why critical limb ischemia criteria are not applicable to diabetic foot and what the consequences are

Neuropathy, peripheral arterial occlusive disease and microvascular disturbances are important factors contributing to foot problems in diabetic patients. In the diabetic foot with ischemia, the alterations in skin microvascular function are pronounced including severely reduced capillary circulation and abolished hyperaemic responses. These microvascular disturbances, which are superimposed on the already existing structural diabetic microangiopathy, are compatible with a state of "chronic capillary ischemia" and an increased shunting of blood through arteriovenous channels. This maldistribution of blood in skin microcirculation is not detected by measurement of peripheral blood pressure (systolic ankle blood pressure, systolic toe blood pressure). As indicated in several studies toe blood pressure is a poor predictor of local tissue perfusion, tissue survival and healing of chronic foot ulcers. Consequently, the disturbances in peripheral tissue perfusion of the diabetic foot may be underestimated leading to delayed vascular interventions and/or medical treatment. Thus, measurements of peripheral blood pressure, e.g. toe blood pressure, should be combined with investigations of local tissue perfusion in order to get an adequate estimation of peripheral tissue perfusion in diabetic patients. For this purpose local skin microcirculation can be investigated by transcutaneous oxygen tension of the forefoot. Also, due to these reasons, the threshold for revascularization should be lower in diabetic patients with foot ulcer.     

Evaluation of vascular and metabolic deficiency in patients with large leg ulcers.

A consecutive series of 50 patients with large leg ulcers (surface area > 100 cm2) were investigated for evidence of arterial, venous and nutritional problems. Arterial insufficiency was found in 34%, venous reflux in 50%. A group of eight patients had no arterial or venous problem but had serious deficiencies of vitamin C and zinc. Arterial bypass was performed successfully in 15 of the 17 patients with arterial disease. All patients had a mesh split-skin graft. The 25 with venous incompetence had compression bandaging; in these patients the ulcer had healed on discharge but 10 had recurrent ulceration within 6 months. The leg ulcers in patients with corrected arterial insufficiency healed significantly more rapidly than those with venous incompetence. The ulcers in those with nutritional deficiency healed promptly after skin grafting and correction of the deficiency. It is important to be aware of arterial insufficiency and nutritional deficiency in patients with leg ulcers, as such deficiencies may contribute to the non-healing of an apparently straightforward leg ulcer.     

Leg ulcer etiology--a cross sectional population study

Three hundred eighty-two patients with active leg ulcers were clinically examined after random selection out of a population of 827 patients identified within a previous cross-sectional population survey. Bidirectional Doppler ultrasonography was used for objective assessment of arterial and venous circulation. The purpose was to register causative factors and the etiologic spectrum. Venous insufficiency was present in 332 (72%) of 463 legs with active ulceration; deep insufficiency occurred in 176 (38%), and purely superficial insufficiency was present in 156 (34%). Ankle/brachial index was 0.9 or less in 185 (40%) of ulcerated legs. Venous insufficiency was the dominating causative factor in 250 legs (54%), of which 60% was the result of deep venous insufficiency. Arterial insufficiency was judged to be the possible dominating factor in 12%, and 6% showed clearly ischemic ulcers. Mixed ulcers with combined arterial and venous insufficiency were found to be common as were patients with diabetes and arterial impairment. In 10% of the legs a multifactorial origin was present, and in 10% no venous or arterial impairment was detectable. Thus after classification of causes 40% of all ulcerated legs showed potentially surgically curable circulatory disturbances. It is necessary to objectively assess all patients with chronic leg ulcers to be able to detect patients with potentially surgically curable disease.     

Prognostic Significance of Distal Blood Pressure Measurements in Patients with Severe Ischaemia

The clinical course was followed and the ankle and toe blood pressures were measured with the strain gauge technique on 5 occasions during 2 years in 43 patients with pain at rest and/or ischaemic ulceration due to severe ischaemia of the legs on the basis of occlusive arterial disease. Although arteriosclerosis of the legs in non-diabetic patients is generally considered a benign disease from the standpoint of limb survival, the critical level of TPI (systolic toe blood pressure/systolic arm blood pressure) was found to be 0.07 as a TPI below this value was associated with an overall 82% risk of amputation. With TPI above 0.07, the chance of successful conservative therapy was about 40%. Diabetics with severe ischaemia must be regarded as a high risk group in respect of amputation (64%) and lethality (64%). A variance analysis was made on the pressure data: In patients with low pressure peripheral vascular beds, the TPI must change more than 0.15 units from one examination to another before the alteration can be considered significant at the 99% confidence level.     

Incidence of the radial steal syndrome in patients with Brescia fistula for hemodialysis: its clinical significance

The Brescia fistula is the method of choice for providing vascular access in patients who have chronic kidney failure that requires hemodialysis. This study investigated hand hemodynamics in patients with Brescia fistulas to determine the incidence of radial steal and its relationship to symptoms of arterial insufficiency of the hand. Twenty-three patients, one of whom had symptoms of arterial insufficiency, were studied. Thumb systolic blood pressure was determined by photoplethysmography under resting conditions and with the fistula, radial, and ulnar arteries occluded successively by digital pressure. The brachial pressure was determined by Doppler ultrasonography and the thumb/arm pressure ratio was determined for each experimental condition. The presence of a Brescia fistula resulted in a 40% reduction of the thumb blood pressure (median thumb/arm ratio = 0.61), which returned to normal (median ratio = 1.03) when the fistula was occluded. Occlusion of the radial artery distal to the fistula resulted in a significant increase in thumb blood pressure (median ratio = 0.89; p less than 0.001), indicating the presence of radial steal. This phenomenon occurred in 21 of the 24 fistulas (88%) studied. This study demonstrated that the radial steal phenomenon occurs in most patients with Brescia fistulas but in only a small number of these patients do symptoms of arterial insufficiency develop.     

Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization

OBJECTIVES: The natural history of limbs affected by ischemic ulceration is poorly understood. In this report, we describe the outcome of limbs with stable chronic leg ulcers and arterial insufficiency that were treated with wound-healing techniques in patients who were not candidates for revascularization. METHODS: A prospectively maintained database of limb ulcers treated at a comprehensive wound center was used to identify patients with arterial insufficiency, defined as an ankle-brachial index (ABI) <0.7 or a toe pressure <50 mm Hg. Patients were treated without revascularization when medical comorbidity or anatomic considerations did not allow revascularization with acceptable risk. Ulcers were treated with a protocol emphasizing pressure relief, débridement, infection control, and moist wound healing. Risk factors analyzed for their affect on healing and amputation risk included age, gender, diabetes mellitus, chronic renal insufficiency (serum creatinine > 2.5 mg/dL), severity of ischemia measured by ABI or toe pressure, wound grade, wound size, and wound location. RESULTS: Between January 1999 and March 2005, 142 patients with 169 limbs having arterial insufficiency and full-thickness ulceration were treated without revascularization. Mean patient age was 70.8 +/- 4.5. Diabetes mellitus was present in 70.4% of limbs and chronic renal insufficiency in 27.8%. Toe amputations or other foot-sparing procedures were performed in 28% of limbs. Overall, limb loss occurred in 37 patients. By life-table analysis, 19% of limbs required amputation < or =6 months of initial treatment and 23% at 12 months. Complete wound closure was achieved in 25% by 6 months and in 52% by 12 months. Statistical analysis showed a correlation between ABI and the risk of limb loss. In patients with an ABI <0.5, 28% and 34% of limbs experienced limb loss at 6 and 12 months, respectively, compared with 10% and 15% of limbs in patients with an ABI >0.5 (P = .01). The only risk factor associated with wound closure was initial wound size (P < .005). CONCLUSIONS: Limb salvage can be achieved in most patients with arterial insufficiency and uncomplicated chronic nonhealing limb ulcers using a program of wound management without revascularization. Healing proceeds slowly, however, requiring more than a year in many cases. Patients with an ABI <0.5 are more likely to require amputation. Interventions designed to improve outcomes in critical limb ischemia should stratify outcomes based on hemodynamic data and should include a comparative control group given the natural history of ischemic ulcers treated in a dedicated wound program.     

Treatment of stenosis of the aortic orifice by the method of balloon dilatation

Methods for balloon dilatation of stenosis of the aortic orifice through an arterial and venous approaches are suggested. The method was approved in treatment of 51 patients whose ages ranged from 4 to 63 years. Retrograde advancement of the balloon to the constricted part is most rational. In antegrade movement of the balloon there is a hazard of inflicting injury to the structures of the mitral valve (4 cases). Both methods produce a similar therapeutic effect: the area of the orifice increased 4.3 times, the systolic pressure gradient reduced by 3.3 times. II degree aortic insufficiency developed in 2 patients and I degree insufficiency in 3 patients. The method may be an alternative in the treatment of valvar and membranous subvalvular aortic stenosis.     

Postthrombotic or non-postthrombotic severe venous insufficiency: impact of removal of superficial venous reflux with or without subcutaneous fasciotomy

BACKGROUND: Severe chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy. MATERIAL: In eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO(2)) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed. RESULTS: There were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO(2) did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO(2) increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy. CONCLUSIONS: Patients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO(2), which seems to promote ulcer healing.     

The toe pole test for evaluation of arterial insufficiency in diabetic patients.

OBJECTIVES: to evaluate if the pole test at the toe level can be used for assessment of arterial insufficiency in diabetic patients. METHODS: twenty-five legs in 23 diabetic patients suffering from leg ischaemia were examined prospectively. A laser Doppler probe was attached to the pulp of the first toe to monitor perfusion continuously before and after occluding the arterial inflow with a cuff and during elevation of the leg until perfusion disappeared (the pole test). At ankle level the examinations were made similarly but with an ankle cuff and a hand-held Doppler. RESULTS: in the 44% (11/25) of the legs where it was possible to compare cuff blood pressure at ankle level with the pole test, the cuff measurements were significantly higher (p <0.01). In 13 of the remaining 14, maximal elevation did not result in disappearance of the Doppler signal. At toe level where 76% (19/25) of the legs could be compared, there was no significant difference between the two methods. CONCLUSION: the pole test can be used at the toe level to evaluate arterial insufficiency in diabetes. When used in the toe, the pole test can assess pressures below 55-70 mmHg, while only pressures below 45 mmHg can be determined at the ankle level. Falsely elevated blood pressure in diabetics is probably of less importance in digital arteries than in ankle arteries, which makes cuff pressure at toe level a more acceptable approximation.     

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency.

OBJECTIVE: Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment. METHODS: Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined. RESULTS: Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n = 34) were factors that were independently associated with delayed healing (P <.01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to $2711. CONCLUSION: The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency.     

Orthostatic changes in first-toe blood pressure in normal subjects and in patients with occlusive arterial disease

Orthostatic changes in first-toe systolic blood pressure, measured with cuff and strain-gauge technique, were compared with changes expected according to hydrostatic calculations. Twenty-five limbs with occlusive arterial disease were studied. When the first toe was lowered 40 cm below the heart, the toe blood pressure--corrected for changes in systemic blood pressure--rose on median 3.9 (-8.7 to 11.4) mmHg more than expected. The difference was statistically significant. Elevation of the first toe 40 cm above the heart did not lead to significant deviation from the expected blood pressure. Twelve normal limbs showed no significant deviations in blood pressure during the orthostatic changes. It is proposed that the additional increase in the indirectly measured systolic pressure also represents an additional increase in the mean arterial blood pressure. The mechanism of this additional increase seems to be reflex vasoconstriction in the distal tissues, reducing the pressure gradient across the proximal collateral vessels. The additional increment may contribute to the abnormalities of local blood flow regulation observed in ischaemic limbs.     

Radical treatment of mal perforans in diabetic patients with arterial insufficiency

Forty patients with diabetes mellitus and severe mal perforans underwent dorsal excision of the involved metatarsal head with primary closure of the plantar ulcer. Patients were screened before operation with noninvasive studies documenting pulse examination, ankle pressure index, and toe blood pressures. Fifteen of 40 patients (38%) had no palpable pedal pulses. Three patients had vascular reconstruction before metatarsal head resection. Mean toe pressure of the entire group was 135 +/- 35 mm Hg (range, 60 to 190), with six patients having a pressure less than 100 mm Hg. All patients had primary healing of the plantar wound and secondary healing of the dorsal incision with no amputations or readmissions for forefoot sepsis in the mean follow-up of 38.5 months (range, 2 to 54 months). In seven patients with recurrent ulcers, no relationship was found between measured indexes of forefoot perfusion and recurrence. However, all patients with recurrence were noncompliant in returning for follow-up orthotic care. This technique provides a means to ensure rapid healing of severe mal perforans while decreasing hospitalization, wound care, and periods of immobilization and is applicable in diabetic patients with arterial insufficiency and toe pressure of at least 60 mm Hg.     

A review of microvascular measurements in wound healing

The microcirculatory evaluation in patients affected by arteriopathic or venous ulcers is usually carried out using laser Doppler flowmetry, transcutaneous oxygen (transcutaneous pressure of oxygen, TcPO(2)), and carbon dioxide (transcutaneous pressure of carbon dioxide, TcPCO(2)) measurements and capillaroscopy. These techniques provide significant pathophysiologic and prognostic information. TcPO(2) and TcPCO(2) diagnose and classify the extent of arterial disease in the leg ulcers caused by arterial disease; the prognostic value is recognized, though doubts about its prognostic potential exist in the case of leg ulcer. Laser Doppler flowmetry is able to identify the first functional impairment in the early stages of the arterial disease and in the complicated venous insufficiency. Capillaroscopy gives us morphological and quantitative parameters of the capillary bed that is damaged in arteriopathic and venous ulcers; nevertheless, it does not provide us with definite prognostic indexes. Combining the 3 methods may contribute to yield objective measures in the clinical management of lower extremity ulcers.     

Microcirculatory haemodynamics before and after vascular surgery in severe limb ischaemia--the relation to post-operative oedema formation

To determine whether postoperative oedema could be predicted preoperatively by microcirculatory parameters, we studied nutritive capillary blood flow in 21 patients before and after limb salvage procedures. All patients had severe lower limb ischaemia and underwent femoro-popliteal or femoro-crural bypass surgery. The systolic ankle-branchial arm index and systolic toe pressure were used as macrocirculatory parameters. Intravital capillary microscopy was used to measure red blood cell (RBC) and peak RBC velocity and time to peak RBC velocity after release of a 1 min arterial occlusion in the nailfold of the toe. Transcutaneous pO2 was measured on the dorsum of the foot at rest, during oxygen inhalation and following a release of a 5 min occlusion. After surgery the mean systolic ankle-brachial index and systolic toe pressure and all transcutaneous pO2 parameters improved significantly (P less than 0.001). Mean peak RBC velocity increased from 0.156 mm/s to 0.310 mm/s (P less than 0.05), indicating that the reactive hyperaemic response in the capillary bed had improved. Eleven patients developed postoperative oedema. There were no differences in postoperative macro and microcirculatory parameters between the patients with oedema (n = 11) and those without oedema (n = 10). However, preoperatively RBC velocity and peak RBC velocity were significantly lower (P less than 0.05) and time to peak RBC velocity was significantly longer (P less than 0.01) in patients who developed oedema. These findings show that in patients with severe limb ischaemia vascular surgery improves both macro- and microcirculatory blood flow, but that these patients develop oedema after vascular surgery when microcirculatory blood flow is compromised preoperatively.     

Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia

PURPOSE: Noninvasive measurements of limb systolic pressures are used routinely in the assessment of the severity of peripheral arterial disease, including the evaluation for critical limb ischemia. However, ankle pressures cannot be measured reliably in patients with medial calcification, which is especially common among patients with diabetes. Skin lesions on the toes or previous digital amputations may preclude the measurement of toe pressures. Measurements of skin perfusion pressure (SPP) are not subject to such limitations and were shown to be useful in the assessment of the severity of peripheral arterial disease. Because toe pressure is often used in the evaluation of severity of arterial disease and in the assessment for critical ischemia, we undertook to study whether there is a sufficient correlation between toe pressure and foot SPP that would allow the use of SPP measurements when toe pressures cannot be measured. METHODS: Measurements were carried out in 85 limbs of 71 patients referred to the vascular laboratory for evaluation for peripheral arterial disease. Diabetes mellitus was present in 43 patients. Each patient had foot SPP and toe pressure measurements. Toe pressures measured with photoplethysmography were correlated with foot SPP measured with laser Doppler scanning. RESULTS: There was a strong linear correlation between SPP and toe pressure (r = 0.87; P <.01). Also, significant correlation was found in both the patients with diabetes and the patients without diabetes (r = 0.85 and 0.93, respectively; P <.01 in both cases). CONCLUSIONS: We concluded that SPP measured in the foot correlates well with toe pressure and can be substituted for toe pressure measurement in patients in whom toe pressures cannot be measured.     

Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: the importance of concomitant arterial and venous disease

PURPOSE: We assessed the etiology and the prevalence of peripheral arterial and venous disease in leg ulcers in patients with rheumatoid arthritis and systemic sclerosis and analyzed the outcome after treatment of macrovascular disease. METHODS: A clinical study on 15 consecutive patients with chronic leg ulcers in collagen vascular disease (nine patients with rheumatoid arthritis, six patients with systemic sclerosis) was carried out in a referral center. Angiography was used when the ankle-arm index was less than 0.8; venography was used when venous reflux was detectable by means of a hand-held Doppler examination. Therapies included percutaneous transluminal angioplasty (seven patients), femoropopliteal bypass grafting surgery (one patient), saphenectomy of the greater saphenous vein (six patients), and split skin graft (11 patients). RESULTS: All patients with rheumatoid arthritis exhibited a multifactorial etiology of their ulcers: four of nine patients had peripheral arterial disease, and five of nine patients had venous insufficiency. In one of these patients, arterial and venous disease was combined. Five of six patients with systemic sclerosis exhibited a multifactorial etiology of their ulcers: three of six patients had peripheral arterial disease, and three of six patients had venous insufficiency. One of these patients had both arterial and venous disease. In patients with rheumatoid arthritis, healing was achieved in six of nine patients, and marked improvement occurred in two of nine patients. A below-knee amputation was necessary in one patient with rheumatoid vasculitis. In patients with systemic sclerosis, healing was achieved in three of six patients, and marked improvement occurred in the other three patients. CONCLUSION: Most leg ulcers in patients with rheumatoid arthritis and systemic sclerosis disclose a multifactorial etiology. Relevant arterial and venous disease can be found in approximately half the patients. Our study suggests that revascularization and vein surgery improve the healing of leg ulcers in patients with collagen vascular disease. A prospective trial is now required to confirm these results.     

Skin perfusion pressure in the prediction of healing in diabetic patients with ulcers or gangrene of the foot

The measurement of skin perfusion blood pressure (SPP) estimated by an isotope clearance technique has been used to predict the healing of ulcers or gangrene of the foot in 61 diabetic subjects. Healing followed conservative treatment or local surgery in 1 of 21 cases if the SPP was less than 40 mm Hg but in 35 of 40 with higher values for SPP. Healing was unlikely if the toe blood pressure was less than 40 mm Hg or the ankle systolic pressure was less than 80 mm Hg. It is recommended that the SPP be measured in patients in whom confident predictions of healing cannot be made on the basis of ankle pressure or other measurements.     

Pulsating varicose veins!! The diagnosis lies in the heart

Right heart failure is associated with increased systemic venous pressure, which can be diagnosed clinically with the findings of elevated jugular venous pressure, pulsatile liver and distinctive cardiac murmurs (precordial systolic). Severe tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of varicose veins. We report three cases that were referred to the vascular clinic of Royal Perth Hospital in which the patients involved had unilateral (right leg) varicose veins and chronic venous ulcers. On clinical examination all three patients had pulsations along the course of the varicose long saphenous vein up to the mid calf. The main differential diagnosis was arterio-venous malformation, which was excluded by compression of the sapheno-femoral junction and demonstrating absence of pulsation in the long saphenous vein. A venous duplex scan showed a grossly incompetent sapheno-femoral junction with abnormal wave forms. Two of the cases were managed conservatively with compression dressing. The option of sapheno-femoral junction ligation was reserved in one patient who had unsettling cellulitis and oedema of the lower limb in spite of compression dressing and optimal conservative management. All three patients had improvement in ulcer size at 3-month follow up with compression therapy. This article highlights that in cases of right heart failure the venous pressures can be felt as low as the mid calf level and that can be a cause of the venous ulcers. There should be a high suspicion of right heart failure in patients with late onset venous insufficiency.