Arterial Ulcer

Question 1

Aetiology of arterial ulcers

Answer 1

Peripheral artery disease from atherosclerosis leads to a lack of blood flow to the capillary beds of lower extremities
Pressure on the skin leads to damage → repair is hindered by the poor tissue perfusion
Microangiopathy, neuropathy and capillary autoregulation

Question 2

Risk factors for arterial ulcers

Answer 2

Smoking
Diabetes
Hyperlipidaemia
>40
Cardiovascular disease
Low levels of exercise
Hypertension
Vasculitis
Arterial fibrodysplasia
Trauma

Question 3

Symptoms and signs of arterial ulcers

Answer 3

Painful arterial ulcer
- “Punched out” appearance - well-defined
- Covered with slough and necrotic/gangrenous tissue
- Minimal exudate
- Grey or yellow fibrotic base
- Undermining skin margins
- Often on the distal ends of the limbs (between toes, lateral foot, ankle)
- Pain worse at NIGHT and on leg elevation
- RELIEVED by HANGING the leg out of the bed or sleeping in a chair

Weak or absent peripheral pulses
Cold skin
Thin, shiny skin
Absence of hair

Question 4

Investigations for arterial ulcers

Answer 4

CK: check for muscle damage

Duplex USS: peak systolic velocity ratio >2 (stenosis)
Continuous wave Doppler USS: Pulsatility index decrease

Catheter angiography, CT angiogram, MR angiography: anatomical detail of stenoses or occlusion

Question 5

Management for arterial ulcers

Answer 5

Conservative:
* RF modification: statins + clopidogrel
* Pain management
(compression bandaging CI)
Medical:
* IV prostaglandins
* Hyperbaric oxygen therapy
Surgical
* Chemical lumbar sympathectomy
* Bioengineered skin substitutes
* Angioplasty (endarterectomy)
Bypass operation

Question 6

Symptoms and signs of neuropathic ulcers

Answer 6

Painless ulcer
- Found at pressure sites e.g. soles, heels, toes, metatarsal heads
- Variable size and depth
- Granulating base
- May be surrounded by or underneath a hyperkeratotic lesion e.g. callus

Warm skin
Abnormal sensation: peripheral neuropathy
Normal peripheral pulses (but cold and weak pulses if neuroischaemic)

Question 7

Investigations for neuropathic ulcers

Answer 7

ABPI <0.8 = neuroISCHAEMIC (otherwise normal)
X-ray: exclude osteomyeelitis

Question 8

Management for neuropathic ulcers

Answer 8

Wound debridement
Regular repositioning, appropriate footwear and good nutrition