How should I assess the severity of arterial insufficiency in a patient with an arterial ulcer?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025Updated: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

To assess the severity of arterial insufficiency in a patient presenting with an arterial ulcer, the primary method is to measure the Ankle Brachial Pressure Index (ABPI) ,,.

  • Clinical Assessment: Begin by asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia . Examine the legs and feet for evidence of critical limb ischaemia, such as ulceration, and palpate the femoral, popliteal, and foot pulses . However, be aware that the absence of foot pulses may indicate arterial insufficiency, but palpation alone is not sufficient to rule it out ,.
  • ABPI Measurement: The ABPI is the ratio of the ankle systolic blood pressure to the brachial systolic blood pressure ,. The patient should be resting and supine if possible . Record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis, and, where possible, peroneal arteries . Measurements should be taken manually using a Doppler probe of suitable frequency in preference to an automated system . Document the nature of the Doppler ultrasound signals in the foot arteries . Calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure .
  • Interpretation of ABPI Values:
    • Less than 0.5: Severe arterial insufficiency is likely, and compression stockings are contraindicated ,. The person should be referred urgently for specialist vascular assessment ,.
    • Greater than 0.5 to less than 0.8: Arterial disease or mixed arterial/venous disease is likely ,. Compression should generally be avoided, but reduced compression can be used under specialist advice and with strict supervision ,. The person should be referred for specialist vascular assessment ,.
    • Between 0.8 and 1.3: Arterial disease is unlikely, and compression stockings are generally safe to wear ,.
    • Greater than 1.3: High ABPI values may be due to arterial calcification, common in conditions such as diabetes, rheumatoid arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure ,. For values above 1.5, the vessels are likely to be incompressible, and the result cannot be relied on to guide clinical decisions ,. The person should be referred for specialist vascular assessment ,.
  • Considerations for Patients with Diabetes: Do not exclude a diagnosis of peripheral arterial disease in people with diabetes based on a normal or raised ABPI alone . Pulse oximetry should not be used for diagnosing peripheral arterial disease in people with diabetes .
  • Referral: People with chronic limb-threatening ischaemia should be referred urgently to a vascular multidisciplinary team . All people with peripheral arterial disease should be provided with information about their condition, tailored to their individual needs, to facilitate shared decision-making and help prevent disease progression ,.

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