Arterial Ulcers

Abstract

Oxygen is delivered to tissue by way of arterial circulation. When there is inadequate oxygen delivery to the tissue it starts to become stressed and  when oxygen delivery becomes critically low the tissue begins to die. This condition is known as an arterial leg ulcer and it is estimated that there are approximately 500,000 of these types of wounds in the United States per year,. Of note, these wounds are specifically not inclusive of “neuro-ischemic” diabetic foot ulcers (which are discussed in the Diabetic Foot Ulcer session).  In patients with arterial leg ulcers there are three significant clinical interventions that need to occur. First, the effected area needs to be re-vascularized; this can occur using several types of procedures, in particular endovascular or open.  However, in approximately 15 percent of all patients this initial step cannot be adequately accomplished. In patients that cannot be re-vascularized there is a 50 percent chance of losing the limb within six months of initial presentation.  Once re-vascularization has occurred, the second phase is to debride the wound to promote healing through the formation of a healthy tissue matrix. There are a variety of diagnostic tests to determine if the tissue has adequate circulation to heal; including physical examination and the use of a hand held Doppler probe and blood pressure cuff. Known as the ankle brachial index, this method is preferable in determining adequate circulation in an arterial leg ulcer. Tissue viability is determined by looking at the blood pressure ratio between the arteries of the foot and leg and the brachial blood pressure of the arm. Finally, if necessary, reconstruction of the effected area, to promote complete wound closure, is required. This reconstruction can be either surgical (full-thickness flap procedure) or medical (implanting artificial skin matrices and/or negative pressure therapy).

References

Federman DG, Ladiiznski B, Dardik A, Kelly M, Shapshak D, Ueno CM, et al. Wound healing society 2014 update on guidelines for arterial ulcers. Wound Repair Regen. 2016;24(1): 127–35

The society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59:220–34