Arterial ulcers

Question 1

What are arterial ulcers?

Answer 1

A localised area of damage and breakdown of skin due to inadequate arterial blood supply.
- Usually seen on the feet of patients with severe atheromatous narrowing of the arteries supplying the legs.

Question 2

What causes arterial ulcers?

Answer 2

The ulcers are caused by a lack of blood flow to the capillary beds of the lower extremities/ Peripheral arterial/vascular disease.  

Question 3

What are the risk factors for arterial ulcers?

Answer 3

• Coronary heart disease 
• History of stroke or TIA  
• Diabetes mellitus  
• Peripheral arterial disease (e.g. intermittent claudication) 
• Obesity and immobility  
• smoking, hypertension, and hyperlipidaemia- all things that damage the arteries in general. 
• Hx of vascular disease, particularly peripheral vascular disease 
• Age >40 years 
• low levels of exercise 

Question 4

What are the presenting symptoms of arterial ulcers?

Answer 4

• Often DISTAL - at the dorsum of the foot or between the toes  
• Punched-out appearance  
• Often elliptical with clearly defined edges  
• The ulcer base contains grey, granulation tissue  
• NIGHT PAIN - hallmark of arterial ulcers  
• Pain is worse when supine (because arterial blood flow is further reduced when supine) 
• Pain is relieved by dangling the affected leg off the end of the bed  

Question 5

What signs of an arterial ulcer can be found on physical examination?

Answer 5

• Night pain and often severe tenderness 
• Punched-out appearance/well-defined borders 
• Hairlessness  
• Pale skin  
• Absent pulses  
• Nail dystrophy  
• Wasting of calf muscles  
• Usually involves the foot, particularly pressure points(e.g., lateral malleolus, tips of the toes) 
• Evidence of gangrene/necrosis 
• Minimal exudate 
• Surrounding skin –cold, shiny, hairless 
• Signs of PVD e.g.6 Ps 

Question 6

What investigations are used to diagnose/ monitor arterial ulcers?

Answer 6

1. Duplex ultrasonography of lower limbs - assess patency of arteries and potential for revascularisation/bypass surgery 
2. ABPI - ankle-brachial pressure index: non-invasive, assess peripheral arterial perfusion in the lower limbs 
3. Percutaneous angiography - minimally invasive procedure that opens blocked coronary arteries 
4. ECG  
5. Fasting serum lipids, fasting blood glucose and HbA1c (diabetes is a major risk factor) 
6. FBC - anaemia can worsen the ischaemia 

Question 7

How are arterial ulcers managed?

Answer 7

1. Lifestyle changes → smoking cessation & diet change to reduce cholesterol levels
2. Wound care → keep ulcer clean by regularly changing wound dressings
3. Surgical Intervention → can be repaired by skin grafting (thin piece of skin is taken from another site, usually the upper thigh, and placed over the wound)
4. The surgical revascularisation of a limb aims to restore blood flow either by bypassing or angioplasty (re-opening) of narrowed vessels. This improves the healing of an ischaemic ulcer by restoring oxygen and nutrient supply to the tissue.

Question 8

What complications may arise from arterial ulcers?

Answer 8

• Infection
• necrosis
• gangrene
• possibly amputation 

Question 9

Summarise the epidemiology of arterial ulcers

Answer 9

● 22% of leg ulcers
● Prevalence increases with age and obesity