Lecture 4a - Vascular Ulcers Flashcards
What % of all LE ulcers are arterial ulcers?
5-10%
What does an arterial ulcer look like?
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
Where are arterial ulcers normally found?
distal LE
commonly on toes, lateral malleolus, or anterior leg
Is there bleeding in arterial ulcers?
minimal bleeding/drainage
Are arterial ulcers painful?
Usually painful (cramping, aching, or fatigue) but can be masked by neuropathy
- pain increased by activity and elevation of wound are
what type of ulcer is this?
Arterial Ulcer
Describe the arterial ulcer periwound.
- lack of hair
- skin is shiny, thin, dry
- increased fungal growth
- nails are yellow/thickened
- limb is pale/cyanotic or shows dependent rubor
- cold to touch
- usually no edema
- lack palpable pulses
Risk factors for arterial ulcers
- Arterial insufficiency
- Hyperlipidemia/elevated cholesterol
- Smoking
- DM
- HTN
- Trauma
- Advanced Age
What are some causes for Arterial Insufficiency (AI)?
- Trauma
- Acute embolism
- Thromboangiitis
- Buerger’s disease
- Microvascular disease
- Arteriosclerosis/atherosclerosis
What is the primary cause of AI?
Arteriosclerosis: thickening/hardening of arterial walls
What’s the most common form of arteriosclerosis?
Systemic, degenerative process in which arterial lumen is gradually/progressively approached upon
- circulating cholesterol attaches plaque to vessel walls
How does smoking lead to an increased risk for arterial ulcers?
- Nicotine causes vasoconstriction
- Decrease available O2
- Increase clot formation rate & blood viscosity
- Nicotine enhances cholesterol deposition in vessels
- O2 delivery/demand mismatch
What is the #1 modifiable risk factor for PVD?
Smoking
80% of patients with PAD are current or former smokers
Why is Diabetes a risk for arterial ulcers?
- increased calcification
- hyperglycemia impairs all phases of healing
- increased neuropathy prevalence that can mask pain
Which HTN is worse for arterial ulcers?
Systolic HTN is worse than diastolic HTN
- increased force initiates / perpetuates endothelial cell injury
Although ulcers can occur spontaneously, most are caused by _____
trauma
including chemical & thermal traumas
Why is age a risk factor for arterial ulcers?
Difficulty adapting to metabolic demands; plaques build up over time
What does ischemic rest pain look like?
More significant arterial disease, burning pain occurs at night or with elevation and RELIEVED with dependency
If you hear “cramping, burning, fatigue,” you think _____ ulcer
Arterial Ulcer
If you hear that the ulcer is distal to the site of occlusion, repeatable or predictable, we’re thinking ______ ulcer
Arterial Ulcer
Some ways to test for an arterial ulcer include?
- Pulses
- Doppler Ultrasound
- Capillary refill
- Rubor
- Venous filling time
- ABI
- TBI
- Transcutaneous O2 monitoring
- CTA
- MRA
What is a doppler ultrasound?
Handheld probe that makes an audible signal when placed over moving fluid
Which pulses should you check for with arterial ulcers?
- femoral
- popliteal
- dorsalis pedis
- posterior tibial
Which testing is more sensitive to pulses: Palpation or Doppler Ultrasound?
Doppler Ultrasound
Slide says: The absence of palable pulses should be followed up with more sensitive testing such as Doppler Ultrasound.
When testing capillary refill time, how long should you push against the distal tip of the digit for? What is normal refill?
Push against digit for 3 seconds to bland
Normal capillary refill is 3 seconds; AI is >3 seconds
When testing rubor of dependency, patient should lie ______, elevate LE to be tested at ______ degrees for _____ minute(s).
When testing rubor of dependency, patient should lie supine, elevate LE to be tested at 60 degrees for one minute(s).
What is normal return time of arterial blood flow (rubor dependency test)?
15-20 seconds; AI takes longer
What is normal venous filling time?
5-15 seconds
What venous filling time indicates severe AI?
20 seconds
What does segmental pressure measurement help with?
Localizing areas of decreased arterial blood flow by holding doppler US probe over dorsalis pedis or post-tib artery & measure SBP with cuff above malleoli, below knee, or around thigh
Best with ID distal arterial occlusion or stenosis
What pressure drop in segmental pressure measurement testing is indicative of significant arterial occlusion?
drop of >20 mm Hg in adjacent segments
How do you calculate ABI?
Divide systolic pressure of the LE by systolic pressure of the UE
What do lower ABI values correlate with?
Increased severity of atherosclerosis and CAD and PAD
What ABI systolic pressure has poor healing potential?
Systolic pressure of <60-80 mm Hg
If your patient _____, the ABI values will be lower on the day of the test.
Smoked!
Normal ABI value
0.9-1.1
ABI Value Interpretation
1.1-1.3
0.7-0.9
0.5-0.7
<0.5
<0.3
1.1-1.3 Vessel Calcification
0.7-0.9 Mild to moderate AI
0.5-0.7 Moderate AI, intermittent claudication
<0.5 Severe AI, rest pain
<0.3 Rest pain and gangrene
What TBI pressure is indicative of good healing potential?
> 30 mm Hg
What is Transcutaneous Oxygen Monitoring used for?
To evaluate slow healing wounds and evaluate for severity of PVD
How do you perform Transcutaneous O2 Monitoring?
Place electrodes on periwound to measure O2 tension
What do these Transcutaneous O2 Monitoring values mean?
> 50 mm Hg
35 mm Hg
< 30 mm Hg
> 50 mm Hg Normal
35 mm Hg wound should heal
< 30 mm Hg needs surgical intervention
What is Plethysmography?
Pulse Volume Recordings
- place multiple cuffs & pulsatile nature of blood flow causes changes in pressure within the cuff –> picked up by transducer and recorded as waveforms
What is Plethysmography useful for?
Testing in noncompressible pedal arteries and to monitor limbs after revascularization surgery
What does Duplex scanning provide info about?
Blood flow, velocity and turbulence in arteries and veins
How do you perform Arteriography?
Dye injected into artery to better visualize blood flow
More invasive, so only done if surgery is being considered
What is CTA/MRA used for?
CTA = computed tomography angiogram
MRA = magnetic resonance angiogram
3D visualization of blood vessels to detect abnormalities or obstructions
Some ways to treat arterial ulcers/AI include?
local wound care
*ensure proper footwear
* gait/mobility training
* positioning
* exercise
* therapeutic heat
* meds
* surgical debridement
* open arterial surgeries
* atherectomy
* amputation
What 4 things do you need to do in local wound care of arterial ulcers/AI?
- Protect the periwound
- Ensure moist wound bed & debride necrotic tissue
- Don’t compromise circulation (no compression)
- Educate pt/caregivers (intervention strategies, risk factors, foot care)
What type of footwear might a pt w/ arterial ulcer/AI use?
- Temporary footwear when they have bandages or waiting for appropriate footwear
- Permanent footwear extra depth toe box, adequate length and space, accomodate deformities
Gait and mobility training considerations for pts w/ arterial ulcers/AI
- off-loading the wound (use of AD)
- LE weakness
titrated mobility exercises
What positions should you avoid with arterial ulcers/AI?
extreme hip and knee flexion
What type of exercise do you recommend for pts with arterial ulcers/AI?
- Graded exercise program can stimulate collateral vessel formation over time
- Resistive exercise
- Flexibility exercises
How does heat help arterial ulcers/AI?
- Heat causes vasodilation and increases tissue SaO2 by decreasing HgB affinity for O2
Heat is gentle as tissue is fragile and cannot dissipate heat effectively
How can pharmacology help arterial ulcers/AI?
- Pain meds helps decrease pain, reduce anxiety
- Pentoxifylline decrease blood viscosity, decrease platelet aggregation, increase RBC flexibility & vasodilation
- Low dose aspirin decrease blood viscosity
How does a sympathetic block help with arterial ulcers/AI?
Eliminate CNS control over vasoconstriction & improve circulation and healing
Done if revascularization cannot be done
Surgical debridement of arterial ulcers can be done at the same time as ________ _________
revascularization surgery
Do you need to debride arterial ulcers in an OR with sterile techniques?
Yes to decrease the chance of infection
What are some endovascular surgeries for arterial ulcers/AI?
- Balloon angioplasty
- Stent angioplasty
- Drug coated balloon angioplasty
- Drug eluting stent angioplasty
- Atherectomy
_____ cannot be safely done below the knee (it causes clots d/t decreased pressure in vessel) so it has to be balloon angioplasty below the knee
Stent
What is a “kissing stent”?
At iliac, if only one side is done, it pushes all the plaque into the other side so they must do both sides
What are the 2 open heart surgeries for arterial ulcers?
- Bypass
- Endarterectomy
What is the treatment of choice for gangrene?
Amputation
- may be necessary if the pt is not able to heal and circulation is not improved
NOT A FAILURE
3 Precautions with AI
- Compression
- Contraindication: sharp debridement to dry stable heel ulcer or gangrene
- Precaution w/ sharp debridement w/ ABI <0.5 and contraindicated w/ ABI <0.3
What is an indicator of good prognosis for arterial ulcers?
ABI > ___
0.5
What is an indicator of good prognosis for arterial ulcers?
TBI > __ mm Hg
50
What is an indicator of good prognosis for arterial ulcers?
Transcutaneous O2 levels > ___
30
What is the most common type of leg ulcer?
Venous ulcer
Venous wound is usually (superficial/deep) with (regular/irregular) shape and moderate to max drainage
Venous wound is usually superficial with irregular shape and moderate to max drainage
Describe the venous ulcer periwound.
- Skin is dry/scaly
- often has cellulitis/dermatitis
- often find varicosities/previous ulcerations
- Edema (pitting)
- Hemosiderin deposition
- Lipodermatosclerosis
- Pulses are present
review your classification of venous ulcers
idk if we need to know them
C0-C6
What are the 2 pumps that help the venous system?
- Respiratory pump: pressure change with breathing
- Muscle pump: muscle contracts and pushes blood proximal
Venous ulcer risk factors
anything that causes venous hypertension
- Vein dysfunction
- Calf muscle pump failure
- Trauma
- Previous venous insufficiency ulcer
- Advanced age
- DM
What are the most common causes of venous HTN?
- Vein dysfunction
- Muscle pump failure
- both
- obstruction to venous outflow
Is the venous system high or low pressure?
Low pressure
- relies on calf muscle to move blood from distal LEs up against gravity
If you had a previous venous ulcer, the recurrence rate is as high as ___%
81%
_______fold increase in venous sufficiency over age 65
Sevenfold increase
Venous Ulcer Testing Methods (6)
- Venogram
- Ultrasonography
- Homan’s sign
- Well Clinical Prediction guideline
- ABI
- Trendelenburg Test
What is the gold standard to identify DVT?
venogram
- expensive
- invasive with dye
- may cause DVT 5% of the time
Using Wells CPG, what score should be considered to have high probability of DVT and be referred for testing?
Score of 3 or greater
____% of all LE are both arterial and venous ulcers
15-20
difficult since you can treat venous with compression but can’t compress arterial ulcers
If you have an ulcer that is both arterial and venous, ABI of < ____ should not be managed with compression.
ABI < 0.7 = NO COMPRESSION
Trendelenburg test tests for _____ ______.
Vein incompetence
In the Trendelenburg test, you record time when superficial venous distention occurs. < ______ seconds = deep or perforator vein incompetence
<20 seconds
Venous distention occurring shortly after tourniquet is released = superficial vein incompetence
What is normal venous filling time?
5-15 seconds
What is immediate venous filling time indicative of?
Venous insufficiency
Venous Ulcer Tx includes:
- Local wound care
- Compression therapy*
- Vasopneumatic compression devices
- Exercise
- Gait & Mobility Training
- Pharmacology
- Surgical debridement
- Skin grafts
- Vein surgery
4 key factors of local wound care for venous ulcers
- Protect surrounding skin
- absorb drainage
- enhance venous return
- educate pt/ caregivers
Wound care for venous ulcers
- Compression
- biological dressings
- Negative pressure wound therapy
For mild-mod venous insufficiency _____ mm Hg at ankle decreasing to 10 mm Hg at infrapatellar notch
For severe venous insufficiency _____ mm Hg at ankle decreasing to 10 mm Hg at infrapatellar notch
Mild-mod 30-40 mm Hg
Severe 40-50 mm Hg
Contraindications for compression therapy
- ABI <0.7
- Acute infection
- Pulmonary edema
- uncontrolled or severe CHF
- active DVT
- severe claustrophobia
6 types of compression bandages
- Paste bandage (Unna boot)
- Short-stretch (elastic or inelastic)
- Multi-layer compression bandage system (4 layers)
- Circaid (velcro)
- Tubular bandage
- Compression garments
Will someone with venous insufficiency have difficulty walking?
Yes, bc of effects of gravity
Average healing time for venous ulcers (full thickness)
8 weeks
small: 5-7 weeks
larger: 10-16 weeks
30-60% treated with compression will heal within ____ months
3 months
What are predictors of poor prognosis of venous ulcer healing?
- deep vein involvement
- concomitant arterial insufficiency
- high body mass
- increased age
recurrence is common
Venous or arterial?
Venous
Venous or arterial
Arterial
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
Venous or arterial
Arterial
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
Venous or arterial
Arterial
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
Venous or arterial
Arterial
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
Venous or arterial?
Venous
Venous or arterial?
Arterial
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
Venous or arterial
Arterial
- round
- regular shaped
- punched-out appearance
- pale wound bed
- may have necrotic tissue
- may present as dry gangrene-dry, dark, cold, and contracted area
