Arterial ulcers (CV)

Question 1

What are arterial ulcers?

Answer 1

Localised area of damage and breakdown of skin due to inadequate arterial blood supply

Question 2

Where are arterial ulcers usually seen?

Answer 2

On feet of patients with severe atheromatous narrowing of arteries supplying the legs

Question 3

What % of all ulcers do arterial ulcers count for?

Answer 3

10%

Question 4

What do arterial ulcers usually occur secondary to?

Answer 4

Trivial trauma

Question 5

What does prevalence of arterial ulcers increase with? (2)

Answer 5

Age and obesity

Question 6

What is the hallmark feature of arterial ulcers?

Answer 6

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

Question 7

What are the clinical features of arterial ulcers? (9)

Answer 7

• 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)

Question 8

What might you see on examination of arterial ulcers? (8)

Answer 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

Question 9

What might Buerger’s test reveal in arterial ulcers?

Answer 9

May reveal blanching of the foot on elevation to 45 degrees and reactive hyperaemia on lowering the leg, suggesting arterial insufficiency

Question 10

What worsens the pain of arterial ulcers?

Answer 10

Worse when supine (night pain) + on elevation

Question 11

What are some risk factors for arterial ulcers? (7)

Answer 11

• PAD (peripheral artery disease - intermittent claudication, critical limb ischaemia)
• CAD (coronary artery disease)
• Hx of stroke/TIA
• diabetes
• obesity
• smoking
• high cholesterol

Question 12

What are the first-line investigations for arterial ulcers? (3)

Answer 12

• duplex ultrasonography of lower limbs
• ankle brachial pressure index (ABPI)
• percutaneous angiography

Question 13

What do we look for in duplex ultrasonography of lower limbs in arterial ulcers?

Answer 13

Assess patency of arteries and potential for revascularisation or bypass surgery

Question 14

What does ankle-brachial pressure index (ABPI) show in arterial ulcers?

Answer 14

ABPI <0.8 = indicative of arterial ulcers

Question 15

What do different ankle brachial pressure monitoring (ABPI) values mean?

Answer 15

• > 1.3 = calcification of vessels
• 0.8-1.3 = normal
• 0.5-0.79 = moderate arterial disease (claudication)
• <0.5 = critical limb ischaemia

Question 15

What bedside investigation can be done for arterial ulcers?

Answer 15

Capillary refill time (increased)

Question 16

What are the differential diagnoses for arterial ulcers? (10)

Answer 16

• 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)

Question 17

How do you manage arterial ulcers?

Answer 17

• 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

Question 18

What does surgical intervention of arterial ulcers include?

Answer 18

• 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

Question 19

What is a complication of arterial ulcers?

Answer 19

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