Arterial Insufficiency Ulcers

English: A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years. (Photo credit: Wikipedia)

Arterial Insufficiency Ulcers 
(Ischemic ulcers or Ischemic wounds)

Arterial ulcers occurs secondary to inadequate supply of oxygenated blood, which is almost always caused by atherosclerosis, or fatty plaque build-up in the arteries.

Characteristics:

• Etiology: Associated with chronic arterial insufficiency;arteriosclerosis obliterans; artheroembolism;history of minor non-healing trauma.
• Pain: Often severe, intermittent claudication,progressing to pain at rest;may complain of pain nocturnally; pain can be relieved by lowering the leg below heart level (i.e. dangling leg over the edge of the bed).
• Pulses: Decreased or absent.
• Appearance: Round or punched out with sharply demarcated borders, yellow base, or necrosis; irregular,smooth edges; min to no granulation;Minimal to no hair;periwound skin pale; tend to be deep.
• Location: Located mainly on the lateral malleolus, ant. tibial area,on the distal lower leg (toes, feet)
• Temperature: Lower extremities cool to touch.
• Color: Skin is pale on elevation, shiny, taut, and thin; dusky rubor on dependency.
• Drainage: Minimal to no drainage.
• Gangrene: May be present
• Edema: Normal
• Others: Presence of femoral bruit and prolonged venous filling time.

 Risk factors:

• Vascular insufficiency
• Uncontrolled Diabetes Mellitus 
• Limited joint mobility
• Poor footwear that inadequately protects against high pressure and shear
• Obesity
• Structural foot deformity(Charcot foot) and callus formation resulting in focal areas of high pressure   
• Retinopathy (poor eye sight)
• Renal disease
• History of cardiac or cerebrovascular disease; leg claudication, impotence, pain in distal foot
• Increased age/ Elderly patients
• Absence of protective sensation due to peripheral neuropathy

Complications:

It may lead to serious complications (including tissue necrosis, infection and amputation) if left untreated.







Diagnosis:

• Topical Wound Oxygen (two2™)
• Ankle brachial index
• Buerger's test
• Arterial Doppler studies and pulse volume recordings
• Antiplatelet and other rheologic agents
• Address risk factors

Management:

Intervention is focused on increasing the arterial circulation.The affected region can sometimes be revascularized via vascular bypass or angioplasty. Amputation and rehabilitation in extreme cases.

Intervention and Recommendation:

• Cleaning the ulcers -wash and dry feet thoroughly; debridement to remove dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.   
• Rest -if the wound is on the plantar area(walking surface of foot), patient is advised to give rest to foot to avoid enlargement of the ulcer.
• Reducing risk factors - Smoking should be avoided to aid wound healing.
• Limb protection - wear appropriately sized shoes with clean,seamless socks  
• Proper glycemic control in diabetics is important
• Avoid unnecessary leg elevation
• Avoid using heating pads or soaking feet in hot water.
• Inspect legs and feet everyday
• Avoid unnecessary pressure

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