[10] Arterial Ulcers

Question 1

What is an arterial ulcer?

Answer 1

An ulcer caused by reduction in arterial blood flow, leading to decreased perfusion to the tissues, and susbequent poor healing

Question 2

What are the risk factors for arterial ulcers?

Answer 2

Same as those for peripheral arterial disease, including;

• Smoking
• Diabetes mellitus
• Hypertension
• Hyperlipidaemia
• Increasing age
• Positive family history
• Obesity and physical inactivity

Question 3

What are the causes of arterial ulcers?

Answer 3

• 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.

Question 4

What preceding history is likely in arterial ulcers?

Answer 4

Intermittent claudication or critical limb ischaemia (pain at night)

Question 5

What are the history features of an arterial ulcer?

Answer 5

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

Question 6

How do arterial ulcers appear?

Answer 6

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.

Question 7

What happens on handling an arterial ulcer, for example debridement?

Answer 7

There is little or no blood

Question 8

Where do arterial ulcers most often occur?

Answer 8

Distal to sites of trauma, or in pressure areas e.g the heal

Question 9

What other signs of arterial insufficiency may be present with an arterial ulcer?

Answer 9

• Cold limbs
• Reduced or absent pulses
• Necrotic toes
• Hair loss

Question 10

How can pure arterial ulcers be differentiated from neuropathic ulcers?

Answer 10

Sensation is maintaiend

Question 11

What investigation is required in any suspected arterial ulcer?

Answer 11

ABPI measurement

Question 12

What can be done based on the ABPI measurement in arterial ulcers?

Answer 12

Can quantify the extent of any peripheral arterial disease

Question 13

What is a normal ABPI?

Answer 13

>0.9

Question 14

What ABPI is considered to be mild PAD?

Answer 14

0.9-0.8

Question 15

What ABPI is considered to be moderate PAD?

Answer 15

0.8-0.5

Question 16

What ABPI is considered to be severe PAD?

Answer 16

<0.5

Question 17

How can the anatomical location of any arterial disease be assessed?

Answer 17

By clinical examination and imaging,

Question 18

What imaging is done in the investigation of arterial ulcers?

Answer 18

• Duplex ultrasound
• CT angiography
• MRA (magnetic resonance angiogram)

Question 19

What are the categories of management in arterial ulcers?

Answer 19

• Conservative management
• Medical management
• Surgical management

Question 20

What is involved in the conservative management of arterial ulcers?

Answer 20

Lifestyle changes, including smoking cessation, weight loss, and increased exercise

Question 21

How can arterial ulcer patients be supported in exercise?

Answer 21

Specific supervised exercise programmes are available

Question 22

What is involved in the medical management of arterial ulcers?

Answer 22

Suitable pharmacological risk factor modification, including statin therapy, anti-platelet agents such as aspirin or clopidogrel, and optimisation of blood pressure and glucose

Question 23

What is involved in the surgical management of arterial ulcers?

Answer 23

• Angioplasty, with or without stenting
• Bypass grafting for more extensive disease

Question 24

How may non-healing ulcers despite good blood supply be managed surgically?

Answer 24

Skin reconstruction with grafts

Question 25

How can arterial ulcers be prevented?

Answer 25

• 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

Question 26

What are the complications of arterial ulcers?

Answer 26

If left untreated, arterial ulcers can lead to serious complications, including infection, tissue necrosis, and in extreme cases amputation of the affected limb