Arterial Insufficiency Ulcers

Perhaps you are like many health care professionals, and find it difficult to differentiate between venous and arterial ulcers. If so, the following article should help you to learn how to recognize and treat arterial ulcers, also known as ischemic ulcers.

What is an arterial ulcer?

Arterial ulcers are ulcers that occur as a result of a complete or partial blockage of the arteries. Another term for this is arterial insufficiency. Arterial insufficiency occurs as a result of peripheral arterial disease (PAD) and causes decreased perfusion to the tissues distal to an arterial plaque formation.

What causes arterial ulcers?

Arterial ulcers are caused by inadequate circulation, which in turn is caused by arterial insufficiency. The hands and feet most often suffer the consequences of arterial insufficiency. Ulcers may form just at or below the ankle, between the toes, or around bony prominences.

What are the risk factors for the development of arterial ulcers?

There are several health conditions that may place your patient at risk for the development of this type of ulcer, including diabetes, high blood pressure, smoking, obesity, sedentary lifestyle, family history, hyperhomocysteinemia, hypertriglyceridemia, hyperuricemia, and stress. These types of ulcers are more common as a person ages (60’s to 80’s) but may occur earlier in patients with diabetes.

Arterial ulcers are often precipitated by trauma, and a simple bump or scrape to an extremity may be the initial cause. Once formed, these ulcers are slow to heal due to the lack of oxygen and nutrients as a result of PAD.

What are the signs and symptoms of arterial ulcers?

There are several signs and symptoms which should prompt the diagnosis of arterial ulcer. Some of these symptoms are:

– Cool or cold skin

– Reduced or absent pulse in the affected extremity

– Shiny, tight, dry skin

– Skin may be hairless

– Toenails thickened and brittle

– Ulcers small and circular in appearance

–   Wound  edges smooth

 Wound  base is pale in colour

– Minimal fluid drainage (unless  wound  is infected)

How do I assess arterial ulcers?

Doppler ultrasound may be needed to assess pulses as they may be absent or diminished in the affected limb. You will note that the patient’s skin will feel cool to the touch, worsening as you move down the limb. The patient may experience pain at rest or during ambulation.

Pain at rest is caused by diminished blood flow to the toes or foot that may be relieved somewhat when the foot is placed in the dependent position. When the patient elevates the limb above heart level, the foot may become pale; the leg will appear reddened or dusky when the leg is in the dependent position. Edema may or may not be present, depending on whether the patient positions the leg in a dependent position for comfort.

How are arterial ulcers treated?

Affected limbs should not be elevated. At rest, the limb should remain in a neutral position. Patients should be encouraged to walk. Patients with arterial ulcers should not have their limbs compressed with stockings or bandages.

There are some medications (Trental and Pletal) that may help to increase blood flow in patients with PAD. Patients with chronic heart failure may be unable to take Pletal. Data to support the use of such drugs is not widely available.

Complete occlusion of a vessel may require vascular surgery.

 Wound  care in arterial ulcers

There are several principles that should be adhered to when caring for arterial ulcers:

– Assess the  wound  daily for appearance, drainage, increase in size, signs of infection, and moistness

– Document  wound  appearance and size frequently

– Assess blood flow frequently

– Manage pain appropriately

– Cleanse  wounds  with normal saline or another non-cytotoxic cleanser

– Moisturize the skin of the affected limb frequently

– Choose the right dressing for the  wound  in its current state-hydrocolloids, hydrogels, foams, and calcium alginates may be acceptable choices

– Ensure adequate nutritional status

– Be alert to signs of infection and treat aggressively-obtain a  wound  culture when in doubt as to whether infection is present. The  wound  should be cleansed with normal saline prior to culturing the  wound .