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Lower Extremity Wounds: Arterial Ulcers

Lower Extremity Wounds: Arterial Ulcers

Wounds on the lower extremities (LE) are very common and have a significant effect on a patient’s health. Most often they become chronic wounds that require a great deal of care. They are costly for the public health care system as well as the patient.

What is the main cause of Arterial Ulcers?

Arterial ulcers often start as a break in the skin on the leg or foot. It can be caused by dry skin, an injury, or a puncture wound. For most, these injuries will heal with proper care. For those with arterial disease, the wound cannot heal due to poor blood flow. This increases the size of the wound while allowing oxygen and bacteria to enter the wound and subcutaneous tissue. Infection occurs, leading to more damage. Minor scrapes and cuts can then develop into ulcers, the tissue becomes necrotic and black.

Arterial ulcers are also known as ischemic ulcers. They occur because blood flow to the lower extremity (LE) is not adequate. This is the result of occlusion, blood clot, or decreased blood flow secondary to vascular disease, specifically, peripheral arterial disease (PAD). Tissue ischemia is extremely painful. These ulcers generally do not heal unless perfusion (blood flow) is restored. Lower extremity arterial disease (LEAD) includes diseases that affect the arteries in the legs. Most ischemic ulcers occur in the legs and are caused by LEAD. Arterial ulcers are prone to infection.

One-third of adults age 65 and older are affected by LEAD and more are undiagnosed. Damage is silent as many do not have symptoms initially. Symptoms occur once the disease process is advanced. With the advancement of the disease, the risk for morbidity (how sick) and mortality (death) increases.

Symptoms of Arterial Ulcers

As mentioned previously, many are asymptomatic until advanced stages. Once symptoms occur, they include:

  • Intermittent claudication (pain with walking, but improves with rest)
  • Pain, when LE is elevated, improves once dependent (down)
  • Vague complaints of poor mobility
  • Leg weakness
  • Redness when LE dangles and pale color when elevated
  • Cold to the touch
  • Hair loss

These symptoms are often overlooked because they are thought to be associated with aging, musculoskeletal conditions or a sedentary lifestyle.

What are the risk factors for Arterial Ulcers?

Some risk factors for PAD are modifiable (those in your control) while others are hereditary or cannot be changed. Factors you can control include:

  • Smoking: Smoking increases the risk for LEAD significantly 4 times greater. Nicotine is a vasoconstrictor (makes blood vessels smaller). This in turn creates platelets to clump and create blood clots.
  • Diabetes: Type II diabetes is a strong predictor of LEAD and often will affect the smaller blood vessels below the knee. For each 1% elevation in A1C, the risk of death increases by 28%. Managing blood sugars will reduce the risk of vascular damage and amputation of the LE. Insulin is a vascular growth factor and may contribute to the thickening of the smooth muscle fibers in the vascular system.
  • High cholesterol (hyperlipidemia): Hyperlipidemia, or high cholesterol, along with high triglycerides and high low-density lipoprotein (LDL) are risk factors for LEAD. A 10 mg rise in total cholesterol associates a 10% increase in risk. Of note, elevated high-density lipoprotein (HDL) reduces the risk.
  • Hypertension (high blood pressure): Hypertension (high blood pressure, BP) increased the risk of LEAD by three times. Elevated BP significantly increases your risk of cardiovascular disease. However, treatment of high BP does not improve LEAD but will reduce your risk for complications associated with cardiovascular and cerebrovascular disease.

Predisposing Risk Factors

Some predisposing risk factors are modifiable while others are not. That modifiable include:

  • Obesity
  • Inactivity (sedentary lifestyle)
  • Stress
  • Social Isolation

Risk factors that are not modifiable include:

  • Age advancement
  • Gender (higher in males)
  • Postmenopausal women
  • Family history
  • African American ethnicity

Treatment of Arterial Ulcers

The primary treatment is to improve perfusion, increase blood flow to the LE. Risk factors that are modifiable should be addressed aggressively to prevent the progression of the disease. Revascularization can include surgical procedures such as bypass graft (most common) and endovascular procedures such as angioplasty and stent placement.

Non-surgical treatments include:

  • Supervised walking programs
  • Medications (antiplatelet agents, statins to lower cholesterol, pain medications)
  • Hyperbaric oxygen therapy
  • Intermittent pneumatic compression (promotes venous return without affecting arterial blood flow)
  • Nutritional support
  • Diabetes control
  • Prevention and management of infection

Topical treatments for arterial ulcers are much like other wounds. Debridement of necrotic tissue and management of bacteria is the first step. Maintaining a moist environment for healing is important. Ischemic ulcers most often are dry with minimal drainage. There is a high risk for infection. It Is best to use a topical treatment with sustained-release antimicrobial properties (Silvasorb Gel by Medline) along with a moisture retentive dressing. It is recommended to use a non-adherent dressing such as a silicone adhesive Allevyn Life Foam Dressing by Smith & Nephew because the skin surrounding the wound is usually very fragile.

If the wound is ischemic, showing no signs of infection and the surface is dry and necrotic, moisture should not be added. Povidone-iodine 10% swab sticks by Medline can be applied to the wound. Once dry, cover the wound with a dry dressing such as Kerlex made by Covidien or Medline.

 

Prevention of Peripheral Arterial Disease (PAD)

For those with known arterial disease, prevention is important. Here are some things you can do.

  • Examine feet and legs daily for changes in color and temperature. Don’t forget to check between the toe.
  • If you smoke, quit
  • Manage blood sugar, blood pressure, and cholesterol
  • Wear properly fitting footwear and loose socks
  • When sitting, do not cross your legs
  • Avoid cold temperatures
  • Protect LE from injuries
  • Exercise daily as tolerated

 

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