Arterial ulcers (CV) Flashcards
What are arterial ulcers?
Localised area of damage and breakdown of skin due to inadequate arterial blood supply
Where are arterial ulcers usually seen?
On feet of patients with severe atheromatous narrowing of arteries supplying the legs
What % of all ulcers do arterial ulcers count for?
10%
What do arterial ulcers usually occur secondary to?
Trivial trauma
What does prevalence of arterial ulcers increase with? (2)
Age and obesity
What is the hallmark feature of arterial ulcers?
Night pain - worse when lying down because arterial blood flow is reduced even further
Relieved by dangling affected leg off the end of the bed
What are the clinical features of arterial ulcers? (9)
- often distal - commonly involves heel, lateral malleolus, tips of toes, dorsum of foot, between toes
- severe pain, worse on elevation
- punched-out appearance
- well-defined borders
- elliptical
- ulcer base contains grey granulation tissue
- hair loss, shiny, cold and pale skin
- absent pulses
- night pain (hallmark)
What might you see on examination of arterial ulcers? (8)
- punched-out appearance + well-demarcated
- hairlessness
- pale skin
- absent pulses + poor capillary refill
- nail dystrophy
- wasting of calf muscles
- claudication, cold extremities, angina, SOB
- carotid bruits, abdominal aortic and/or popliteal aneurysms
What might Buerger’s test reveal in arterial ulcers?
May reveal blanching of the foot on elevation to 45 degrees and reactive hyperaemia on lowering the leg, suggesting arterial insufficiency
What worsens the pain of arterial ulcers?
Worse when supine (night pain) + on elevation
What are some risk factors for arterial ulcers? (7)
- PAD (peripheral artery disease - intermittent claudication, critical limb ischaemia)
- CAD (coronary artery disease)
- Hx of stroke/TIA
- diabetes
- obesity
- smoking
- high cholesterol
What are the first-line investigations for arterial ulcers? (3)
- duplex ultrasonography of lower limbs
- ankle brachial pressure index (ABPI)
- percutaneous angiography
What do we look for in duplex ultrasonography of lower limbs in arterial ulcers?
Assess patency of arteries and potential for revascularisation or bypass surgery
What does ankle-brachial pressure index (ABPI) show in arterial ulcers?
ABPI <0.8 = indicative of arterial ulcers
What do different ankle brachial pressure monitoring (ABPI) values mean?
- > 1.3 = calcification of vessels
- 0.8-1.3 = normal
- 0.5-0.79 = moderate arterial disease (claudication)
- <0.5 = critical limb ischaemia
What bedside investigation can be done for arterial ulcers?
Capillary refill time (increased)
What are the differential diagnoses for arterial ulcers? (10)
- venous ulcer
- mixed AV ulcer
- neuropathic ulcer
- pressure ulcer
- lymphoedema ulcer
- traumatic ulcer
- malignant ulcer - Marjolin ulcer (SCC in long-standing ulcer)
- vasculitic ulcer (RA, pyoderma gangrenosum)
- infective ulcer (TB, syphilis, leprosy)
- haemolytic anaemia (sickle cell, hereditary spherocytosis)
How do you manage arterial ulcers?
- lifestyle changes - smoking cessation and diet changes to reduce cholesterol
- dressing the ulcer - to prevent infection, regularly change wound dressings
- take care to avoid bandage being tight as this will worsen the ischaemia (ABPI<50 is emergency)
- analgesia
- Abx - if signs of infection and positive swab
- angioplasty and stenting if artery is stenotic or there is a short occlusion + patent artery downstream of the occlusion
- surgical intervention
What does surgical intervention of arterial ulcers include?
- surgical revascularisation of of a limb - restore blood flow by bypassing or angioplasty (reopening) of narrowed vessels
- angioplasty and stenting - if stenotic artery/short occlusion and patent artery downstream of occlusion
- bypass surgery using a venous graft or artificial Dacron graft can be performed if angioplasty not possible
- skin grafting - thin piece of skin is taken from another site (usually upper thigh) and placed over wound - improves healing of ischaemic ulcer by restoring oxygen and nutrient supply to the tissue
What is a complication of arterial ulcers?
Acute limb ischaemia (Painful, Pale, Pulseless, Paralysed, Perishingly cold leg with Paraesthesia) - embolectomy, percutaneous thrombolysis, revascularisation angioplasty, bypass surgery, or amputation of the affected limb
