Lower extremity ulcers are a common occurrence in individuals aged over 60. A combination of risk factors and disease processes in these individuals impact the wound healing stages, which leads to the development of chronic, non-healing ulcers. Arterial ulcers account for 8-10% of all lower extremity ulcers. [1] However, the prevalence might be significantly underreported due to the failure to recognize the etiology of leg ulcers. Wound care specialists need to be aware of the differences between arterial ulcers and other ulcer types to provide effective wound care. 

What are Arterial Ulcers?

Arterial or ischemic ulcers occur due to compromised blood supply to the tissues. As adequate oxygenation and nutrient supply are essential for wound healing stages to progress, a lack of blood supply would significantly impair the wound healing process. This contributes to the development of chronic, non-healing ulcers that are difficult to treat. Ischemic ulcers are extremely painful and tend to occur on the distal end of toes and feet. [2] They are linked with the presence of peripheral vascular disease and have associated features of ischemia. These include:

• Pale skin
• Absent pulsation
• Hairless skin
• Wasting of muscles 

Arterial ulcers are distinct from acute limb ischemia.

Etiology and Risk Factors 

A proper understanding of etiology and risk factors can help wound care specialists and podiatrists in identifying individuals who are prone to the development of arterial ulcers. Some of the etiologies that have been identified in the pathogenesis of arterial ulcers include:

• Atherosclerosis
• Peripheral vascular disease 
• Buerger's disease 
• Sickle cell disease 
• Vasculitis

Arterial ulcers most often occur in middle-aged men who have one or more of the following risk factors:

• Smoking
• Diabetes
• Hypertension
• Dyslipidemia
• Family history
• African American ancestry 

Management Of Arterial Ulcers 

Arterial ulcer treatment should involve a comprehensive assessment by wound care specialists and podiatrists and should address the underlying cause and risk factors. Following basic principles should be kept in mind in the management of arterial ulcers:

• Smoking cessation: As peripheral vascular disease is a significant risk factor for the development of arterial ulcers, smoking cessation is recommended to halt the progression of the disease.
• Regular exercise: Walking helps relieve the claudication pain, and is effective in managing the symptoms of peripheral vascular disease. 30-60 mins of walking should be recommended to patients.
• Adequate nutrition: Optimum nutrition is necessary for wound healing.
• Avoid compression therapy: Patients with arterial ulcers have a compromised blood supply. Therefore, compression therapy must be used cautiously as it might further compromise the already restricted perfusion.

As arterial ulcers are caused due to obstruction of normal blood supply, measures that restore perfusion to the tissues help promote wound healing. [3]

Local Wound Care

Localized wound care depends on the characteristics of the arterial ulcer. Healable ulcers can sustain more aggressive treatments compared to non-healable ulcers which require a more conservative management approach. Following are the steps involved in the local wound care of arterial ulcers:

• Infection Control: Ischemic wounds are prone to contamination with bacteria. Bacterial colonization can impair wound healing as it damages the healthy granulation tissue. Classical signs of bacterial infection may not always be present and can be identified with the help of a bacterial swab of the wound. Silver dressings and cadexomer iodide can be used as a topical treatment of wound infection. Deep tissue infections however require systemic antibiotic therapy.
• Wound Cleansing: A wound free from debris and necrotic tissue is necessary for optimum wound healing. Several commercial wound cleaners are toxic to the granulation tissue, and therefore should only be used for wounds with a heavy bacterial burden. The least harmful wound cleaner is 0.9% normal saline or water. The wound should be cleansed with gentle pressure to dislodge the debris. [4]
• Dressing: Arterial ulcers have a minimal exudate, and the surrounding skin is fragile. Therefore moist, non-adherent dressings are indicated. As arterial ulcers are particularly vulnerable to bacterial contamination, the dressing should be infused with antimicrobial properties for effective infection control.

Medical Management 

Following drugs are prescribed for the medical management of arterial ulcers:

• Antiplatelet drugs: Low dose (75-325mg/day) Aspirin prevents the aggregation of platelets and hence helps to limit the progression of peripheral vascular disease. Clopidogrel can also be used as a better alternative. [5]
• Cilostazol: Cilostazol is a vasodilator drug that is used in the medical management of peripheral vascular disease (PVD). It can be helpful in the management of arterial ulcers. [6]
• Statins: Statin drugs lower the level of lipids in the blood, and are used in the treatment of atherosclerosis. As atherosclerosis is implicated in the pathogenesis of peripheral vascular disease and subsequent arterial ulceration, statins are prescribed.
• Analgesia: Arterial ulcers are painful, and require management with opioids. Pain activates the sympathetic nervous system which leads to vasoconstriction in the peripheral vascular system. Hence, adequate analgesia can also help improve tissue perfusion.

Surgical Management

The primary aim of surgical management is to restore blood supply to the tissues. Indications for surgical treatment include ulcers that are unresponsive to conservative management and critical limb ischemia. Distal vessel patency should be assessed using MR angiography or CT angiography before surgery. 

Following surgical options are available for the management of arterial ulcers:

• Bypass Graft: Bypass graft has been regarded as a "gold standard" in the revascularization of lower limbs. A bypass graft is constructed using the patient's saphenous vein. The results of bypass grafts are generally good and have five-year patency of around 70%. [7]
• Endovascular procedures: Compared to bypass grafts, endovascular procedures are less invasive. Hence they are associated with fewer complications and are now being considered by some authors as the preferred modality for the treatment of arterial ulcers. [8]

Remote Wound Care: Telehealth

Patients with chronic wounds require constant monitoring and assessment by wound care specialists. Unfortunately, frequent in-person visits aren't always feasible for patients who might be bed-bound or unable to access healthcare facilities due to geographical or financial restraints. The role of telehealth is increasingly being studied for providing wound care to patients who otherwise might not be able to access treatment. Telehealth is an excellent adjunct in wound care and can help clinicians provide real-time monitoring to patients despite geographical limitations. 

References:

1. Young JR. Differential diagnosis of leg ulcers. Cardiovascular clinics. 1983 Jan 1;13(2):171-93.
2. Grey JE, Enoch S, Harding KG. ABC of wound healing: venous and arterial leg ulcers. BMJ. 2006 Apr 1;332(Suppl S4).
3. Bonham PA, Flemister BG, Goldberg M, Crawford PE, Johnson JJ, Varnado MF. What's New in Lower-Extremity Arterial Disease?: WOCN's 2008 Clinical Practice Guideline. Journal of Wound Ostomy & Continence Nursing. 2009 Jan 1;36(1):37-44.
4. Maklebust J, Sieggreen M. Pressure ulcers: Guidelines for prevention and management. Lippincott Williams & Wilkins; 2001.
5. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). The Lancet. 1996 Nov 16;348(9038):1329-39.
6. Stevens JW, Simpson E, Harnan S, Squires H, Meng Y, Thomas S, Michaels J, Stansby G. Systematic review of the efficacy of cilostazol, naftidrofuryl oxalate and pentoxifylline for the treatment of intermittent claudication. Journal of British Surgery. 2012 Dec;99(12):1630-8.
7. Daenens K, Schepers S, Fourneau I, Houthoofd S, Nevelsteen A. Heparin-bonded ePTFE grafts compared with vein grafts in femoropopliteal and femorocrural bypasses: 1-and 2-year results. Journal of vascular surgery. 2009 May 1;49(5):1210-6.
8. Albayati MA, Shearman CP. Peripheral arterial disease and bypass surgery in the diabetic lower limb. Medical Clinics. 2013 Sep 1;97(5):821-34.

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