What is an arterial ulcer?
An ulcer caused by reduction in arterial blood flow, leading to decreased perfusion to the tissues, and susbequent poor healing
What are the risk factors for arterial ulcers?
Same as those for peripheral arterial disease, including;
- Smoking
- Diabetes mellitus
- Hypertension
- Hyperlipidaemia
- Increasing age
- Positive family history
- Obesity and physical inactivity
What are the causes of arterial ulcers?
- Restriction to blood vessels due to peripheral vascular disease
- Chronic vascular insufficiency
- Vasculitis
- Diabetes mellitus
- Renal failure
- Hypertension
- Arteriosclerosis and atherosclerosis
- Trauma
- Limited joint mobility
- Increasing age.
What preceding history is likely in arterial ulcers?
Intermittent claudication or critical limb ischaemia (pain at night)
What are the history features of an arterial ulcer?
The ulcer may be painful, and often develops over a long period of time with little or no healing. The pain is typically at night, and relieved by dangling the legs out of the bed
How do arterial ulcers appear?
Initially they have irregular edges, but over time they may become clearly defined. The lesions are often small and deep, with a ‘punched out’ appearance, and gray or yellow fibrotic base.
What happens on handling an arterial ulcer, for example debridement?
There is little or no blood
Where do arterial ulcers most often occur?
Distal to sites of trauma, or in pressure areas e.g the heal
What other signs of arterial insufficiency may be present with an arterial ulcer?
- Cold limbs
- Reduced or absent pulses
- Necrotic toes
- Hair loss
How can pure arterial ulcers be differentiated from neuropathic ulcers?
Sensation is maintaiend
What investigation is required in any suspected arterial ulcer?
ABPI measurement
What can be done based on the ABPI measurement in arterial ulcers?
Can quantify the extent of any peripheral arterial disease
What is a normal ABPI?
>0.9
What ABPI is considered to be mild PAD?
0.9-0.8
What ABPI is considered to be moderate PAD?
0.8-0.5
What ABPI is considered to be severe PAD?
<0.5
How can the anatomical location of any arterial disease be assessed?
By clinical examination and imaging,
What imaging is done in the investigation of arterial ulcers?
- Duplex ultrasound
- CT angiography
- MRA (magnetic resonance angiogram)
What are the categories of management in arterial ulcers?
- Conservative management
- Medical management
- Surgical management
What is involved in the conservative management of arterial ulcers?
Lifestyle changes, including smoking cessation, weight loss, and increased exercise
How can arterial ulcer patients be supported in exercise?
Specific supervised exercise programmes are available
What is involved in the medical management of arterial ulcers?
Suitable pharmacological risk factor modification, including statin therapy, anti-platelet agents such as aspirin or clopidogrel, and optimisation of blood pressure and glucose
What is involved in the surgical management of arterial ulcers?
- Angioplasty, with or without stenting
- Bypass grafting for more extensive disease
How may non-healing ulcers despite good blood supply be managed surgically?
Skin reconstruction with grafts
How can arterial ulcers be prevented?
- Examine feet (especially between toes) and legs daily for any unusual changes in colour, or development of sores
- Management of cardiovascular risk factors, e.g. smoking, blood pressure
- Ensure footwear is properly fitted to avoid points of rubbing or pressure
- Avoid crossing legs when sitting
- Avoid sitting or standing for extended periods
- Avoid cold temperatures
- Protect legs and feet from injury and infection
What are the complications of arterial ulcers?
If left untreated, arterial ulcers can lead to serious complications, including infection, tissue necrosis, and in extreme cases amputation of the affected limb
