1 of 19

MANAGEMENT OF ARTERIAL ULCERS

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

2 of 19

  1. Introduction
  2. Risk Factors
  3. Diagnosis
  4. Investigations
  5. Treatment
  6. Conclusion

Content

Wound Care Training Module - National Wound Care Committee

Content

Wound Care Training Module - National Wound Care Committee

3 of 19

INTRODUCTION

  • Arterial ulcers are ischemic ulcers in patients with peripheral vascular disease.
  • Reduced blood supply to the affected limb impedes healing and causes delay or non-healing of the ulcer.
  • It is crucial to identify arterial ulcers, as the management would involve revascularization to improve the circulation of the affected limb to achieve wound healing.

​

​

Wound Care Training Module - National Wound Care Committee

4 of 19

RISK FACTORS

  • Diabetes mellitus
  • Smoking
  • Dyslipidemia
  • Male
  • Elderly
  • Hypertension
  • Hyperviscosity and hypercoaguable states

Wound Care Training Module - National Wound Care Committee

5 of 19

DIAGNOSIS

  • Diagnosis of arterial ulcer is based on history and physical examination.

Wound Care Training Module - National Wound Care Committee

6 of 19

  1. RISK FACTORS
  2. Identify the above listed risk factors
  1. SYMPTOMS OF CHRONIC LIMB ISCHEMIA
  2. Intermittent claudication – pain in the calf muscles with exercise and relieved by rest
  1. HISTORY OF PREVIOUS MINOR / MAJOR AMPUTATION
  2. A patient with previous major amputation on the contra-lateral limb requires more aggrresive efforts to salvage the currently affected limb
  1. HISTORY OF PREVIOUS VASCULAR INTERVENTION
  2. A non-healing or recurrent wound indicates re-stenosis or thrombosis of previous intervention

RELEVANT HISTORY

  1. NON-HEALING OF A PREVIOUS MINOR OR MAJOR AMPUTATION WOUND

Wound Care Training Module - National Wound Care Committee

7 of 19

  1. EXAMINE OF THE ULCER / WOUND
  2. Pale base and edges with slough
  3. Void of granulation tissue
  4. Dry ulcer with surrounding inflammation
  5. Sites – Pressure points, toes
  1. SIGNS OF CHRONIC LIMB ISCHAEMIA
  2. Muscle atrophy of the affected limb
  3. Hair loss and hyperpigmentation

CLINICAL EXAMINATION

  1. EXAMINATION OF THE PERIPHERAL PULSES
  2. Digital palpation of the peripheral pulses
    • Two plus (++) indicates normal pulse
    • One plus (+) indicates weak pulse
    • Negative (-) indicates absent pulse

Left foot arterial ulcer

Wound Care Training Module - National Wound Care Committee

8 of 19

  1. EXAMINATION WITH A HAND – HELD DOPPLER DEVICE
  2. Waveform of the Doppler signals and measurement of the ankle – brachial systolic index (ABSI) gives an indication of the severity of the disease in the vessels.
  1. TOE PRESSURE MEASUREMENT (when available)
  2. In patients with calcified vessels, where the ABSI maybe normal / high, toe pressure measurement would be accurate to indicate presence or absence of the peripheral vascular disease.

Waveform ABSI Interpretation

Triphasic ≥0.9 – 1.3 Normal

Biphasic 0.4 – 0.9 Peripheral vascular disease

Monophasic ≤ 0.4 Critical limb ischaemia

​

* Note that ABSI may be normal or high with calcified vessels as in diabetic and some renal failure patients.

Wound Care Training Module - National Wound Care Committee

9 of 19

INVESTIGATIONS

  • Non-healing ulcers with absent pulses or abnormal ABSI require radiological imaging to establish the level of disease and to plan subsequent intervention.

Wound Care Training Module - National Wound Care Committee

10 of 19

  • Imaging options available includes;
    • Duplex Ultrasound Scan
    • CT angiography
    • MR angiography
    • DS angiography

​

    • Choice of investigation depends on availability and suitability.

​

    • Foot X-ray may be indicated to exclude underlying osteomyelitis.

Wound Care Training Module - National Wound Care Committee

11 of 19

TREATMENT

  1. Re-vascularisation of diseased vessel
  2. To restore/improve the circulation to the distal ischaemic limb
  3. Can be achieved via open bypass surgery, angioplasty or in combination

​

  1. Wound debridement / minor amputation and wound care
  2. Following revascularization, standard wound care procedures as in Wound Care Algorithm
  3. Special care to be taken to avoid compression bandages and leg elevation

​

Wound Care Training Module - National Wound Care Committee

12 of 19

  1. Pharmacotherapy
  2. Anti-platelet therapy
  3. Statins
  4. Antibiotics when indicated
  5. Analgesia (refer chapter on pain management)

​

  1. Life-style modification
  2. Stop smoking
  3. Diabetic control
  4. Dietary counseling

​

Wound Care Training Module - National Wound Care Committee

13 of 19

  1. Major amputation
  2. Primary amputation to be considered in non-salvageable limb, or patients with non-re-constructible disease and patients with poor cardiac function

​

  1. Rehabilitation
  2. Aim of treatment is for patients to ambulate and resume daily activities

​

Wound Care Training Module - National Wound Care Committee

14 of 19

Phases of amputee rehabilitation

1. Pre-operative

Medical and body condition assessment, patient education, surgical-level discussion, functional expectations, phantom limb discussion

2. Amputation surgery/dressing

Residual-limb length determination, myoplastic closure, soft-tissue coverage, nerve handling, rigid dressing application, limb reconstruction

3. Acute postsurgical

Wound healing, pain control, proximal body motion, emotional support, phantom limb discussion

4. Pre-prosthetic

Residual-limb shaping, shrinking, increasing muscle strength, restoring patient’s sense of control (figure of 8 stump bandaging)

5. Prosthetic prescription/fabrication

Prosthetic prescription will depend on patient cognitive status, medical status, functional status and socioeconomic status

6. Prosthetic training

Prosthetic management and training to increase wearing time and functional use

7. Community integration

Resumption of family and community roles; regaining emotional equilibrium; developing healthy coping strategies, recreational activities

8. Vocational rehabilitation

Assessment and training for vocational activities, assessment of further education needs or job modification

9. Follow-up

Lifelong prosthetic, functional, and medical assessment; emotional support

Wound Care Training Module - National Wound Care Committee

15 of 19

Algorithm for management of arterial ulcer

* In patients with normal toe pressure, allow 2-4 weeks for wound to heal before referring for re-assessment with further imaging

Wound Care Training Module - National Wound Care Committee

16 of 19

CONCLUSION

  • It is crucial to identify an arterial (ischaemic) ulcer, as the management of such an ulcer is different.
  • Prompt intervention to improve the blood supply to the affected limb is important for healing of an ischemic ulcer.

Wound Care Training Module - National Wound Care Committee

17 of 19

TAKE HOME MESSAGES

  • Arterial ulcer is a reflection of a systemic disease. Care should be taken to assess the cardiovascular system.
  • It is crucial to check for the peripheral pulses in all legs with ulcers. Absent pulses will require further assessment to exclude ischaemic ulcer
  • Once identified, patients with ischaemic ulcers will require vascular intervention or revascularization
  • Leg elevation and compression bandages must be avoided in all cases of suspected ischemic ulcers
  • Pain management – ischaemic ulcer is extremely painful

Wound Care Training Module - National Wound Care Committee

18 of 19

REFERENCES

  • Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) European Journal Vascular and Endovascular SurgeryVol 33, Supplement 1, 2007
  •  Hiatt WR. Medical Treatment of peripheral arterial disease and claudication. N Eng J Med. 2001;344:1608–21
  •  J Am Podiatr Med Assoc 91(1): 13-22,2001) Alberto Esquenazi, MD,RobertDiGiacomo, PT

Wound Care Training Module - National Wound Care Committee

19 of 19

THANK YOU

Wound Care Training Module - National Wound Care Committee