Arterial Ulcers Flashcards
What are the most common types of ulcers?
Venous (70%)
Arterial (10%)
Mixed (10%)
What is the differential diagnosis for a leg ulcer?
- Venous ulcer
- Mixed ulcer
- Arterial (atherosclerotic) ulcer
Other:
- Pressure ulcer
- Neuropathic ulcer
- Lymphoedema ulcer
- Traumatic ulcer
- Malignant ulcer (e.g. Marjolin ulcer, squamous cell carcinoma)
- Vasculitis ulcer (e.g. rheumatoid arthritis, pyoderma gangrenosum)
- Infective ulcer (e.g. tuberculosis, syphilis)
- Haemolytic anaemia (sickle cell, hereditary spherocytosis)
When are arterial ulcers most painful?
More painful with legs elevated and drained of blood
When do arterial ulcers present compared to others?
Early because of pain
Occur secondary to trivial trauma
Describe the symptoms associated with arterial ulcers?
Presents with symptoms of PAD, also coronary artery or cerebrovascular disease.
- Claudication
- Rest pain
- Night pain
- Cold extremitis
- Angina
- SOB on exertion
- History of stroke or TIA
What are the risk factors associated with arterial ulcers?
Atherosclerosis RFs including:
- smoking
- diabetes mellitus
- hypertension
- hyperlipidaemia
- strong FH of arterial disease
- male
- evidence of other atherosclerotic disease
- PAD (claudication, impotence, AAA)
What is the typical site for arterial ulcers? What are the characteristics of an arterial ulcer?
Occur where blood supply is the worst (tends to be distal parts of the foot, e.g. between toes) or compressed areas (e.g. ball of foot, lateral malleolus, bony prominences)
Deep, punched-out, dry, often elliptical
What are the signs associated with arterial ulcers?
- Cold, pale limbs
- Poor capillary refill
- Venous guttering
- Absent or weak pulses
- Atrophic skin changes (dry, shiny, hairless)
- Carotid bruits
- Buerger’s test postive
- Abdominal aortic and/or popliteal aneurysms
What does Buerger’s test show in arterial disease?
Buerger’s test reveals blanching of the skin when leg is raised to 45 degrees and reactive hyperaemia on lowering the leg , suggesting arterial insufficiency
What investigations would you do for an arterial ulcer?
- Bloods - FBC (for anaemia as this exacerbates any ischaemia), fasting lipids (for high chol), HbA1c, fasting glucose
- Capillary glucose - quick and reliable way of checking for DM ,50% of which is undiagnosed
- Urinalysis - looks for diabetes, if vasculitis is considered then also look for haematuria/proteinuria
- Duplex ultrasonography of lower limbs (or MRA) - assesses patency of arteries/potential for revascularisation/bypass. alternatively, percutaneous angiography can be performed for assessment and treatmnet (angioplasty) all in one.
- ABPI - checks for arterial disease
- Swabbing - for MC&S*, not routine unless growth
- Biopsy - not unless you suspect Marjolin’s ulcer
*Microscopy, culture & sensitivities
When can you get falsely high ABPI readings?
When people have calcified arteries i.e. diabetics/chronic renal failure . Oedema can also give false readings.
Describe how ABPI is calculated and how you would interpret the results.
ABPI is measured using a manual sphygmomanometer, stethoscope and portable Doppler probe. ABPI is the ratio of the ankle systolic (either dorsalis pedis or posterior tibial) over brachial systolic pressure
ABPI interpretation:
- >1.2 - calcified, stiff arteries in advanced age/PAD
- 1.0-1.2 - normal
- 0.9-1.0 - acceptable
- <0.8 - compression stockings not indicated.
- 0.6-0.9 - claudication
- <0.5 - rest pain and severe disease. Critical limb ischaemia. Urgent referral to vascular surgeon.
*ABPI is a good test. <0.9 values have a sensitivity of 90% and a specificity of 98% for PAD.
Why should you not apply compression bandage when ABPI is <0.8?
Pressure bandage is applied to venous ulcers.
ABPI should be measured even when convinced that the ulcer is venous as if ABPI is <0.8, the pressure must not have pressure bandage applied as this suggests a mixed venous/arterial ulcer which could make ischaemia worse if compressed.
How do you manage arterial ulcers?
Interim :
- Dressing of ulcer - prevents infection
- Analgesia
- Antibiotics in any sign of infection or if swab is positive
Surgical:
- Angioplasty +/- stenting - if artery is stenotic or there is short occlusion and there is a patent artery downstream of occlusion
- Bypass surgery - using a venous graft or artificial Dacron graft if angioplasty not possible
What are the main types of dressings for ulcers?
Low adherence dressings - used if there is little exudate that needs soaking up because they have little adherence.
Hydrogel dressings - useful for hydrating dry ulcers (e.g. arterial) and for encouraging debridement of dead tissue (e.g. diabetic neuropathic ulcers)
Hydrocolloid dressings - contain a gel that covers the ulcer and keeps it moist and protected. Useful for pressure ulcers.
Foam dressings - useful for covering pressure ulcers in areas that are likely to have ongoing pressure (e.g. the heels)
Alginate dressings - like dry algae, they mop up water and are thus useful for wet ulcers (e.g. venous ulcers, fungating ulcers)
Antibacterial dressings - prevent growth of bacteria by incorporating silver, iodine, honey or metronidazole. Little evidence base other than for iodine.
Summarise the presentation of arterial, venous and neuropathic ulcers.
How are ulcers graded?
European Pressure Ulcer Advisory Panel (EPUAP) grades:
- Non-blanching erythema of intact skin
- Partial thickness skin loss or blistering
- Full thickness skin loss. Subcutaneous fat may be visible, but not underlying tendon, bone, muscle etc
- Full-thickness tissue loss with involvement of bone/muscle/tendon.May be covered with thick slough* or eschar**.
