4 - arterial & venous ulcers

Arterial

and

Venous

Ulcers

Arterial and Venous Ulcers

Arterial Ulcer Epidemiology

Leg ulcers occur in approximately 1% of the population at some point in their lives

About 25% of these ulcers are arterial origin

Associated with claudication, rest pain, gangrene and localized ulceration

Located almost exclusively in the distal lower extremity

Ischemia is common especially with smokers, Diabetes and in elderly

Leg ulcers

Concern of the cost

Pain & suffering

Body image change

Struggle for control, independence

Depression, isolation

Social Issues

Arterial & Venous Ulcer Goals

Understand the pathogenesis (underlying medical problems)

Accurate assessment – differentiate between venous, arterial, mixed etiologies

Identify and manage risk factors to facilitate prevention and early intervention

Management of ulceration – underlying etiology(cause) & wound

Arterial UlcersArterial UlcersResult of Reduced Blood Supply due to:Result of Reduced Blood Supply due to:

Emboli - leads to infarction &ischemia

Atherosclerosis(accumulation of plaque) - narrows lumen of artery - diminished arterial blood supply

- decreased delivery of O2 & nutrients

- leads to tissue hypoxia and necrosis

Arterial Ischemia AssessmentArterial Ischemia Assessment

History of:

Cold feetIntermittent claudication - pain in leg/buttock with walkingRest pain - in toes & forefoot Pain aggravated by elevation & relieved by dependencySmoking, diabetes, hypertension, Hyperlipidemia, CAD, age

Arterial Insufficiency Ischemia

Colour – pale Dependent rubor- with - Elevation pallorDecreased capillary refill time

(>15 sec.)Atrophy of subcutaneous fatty

tissueShiny, thin, tightly drawn skinLoss of hair on foot and toes Thick, yellow, brittle nails

Vascular Vascular AssessmentAssessment

InspectionInspection:

Palpation:

Cool to touch Absence of pedal

pulsesBlanch test

Vascular AssessmentVascular AssessmentDorsalis pedis

Posterior tibial

PAD – Peripheral Vascular Disease

Non-healing foot ulcers

Due to impaired delivery of: Oxygen Nutrients Antibiotics

Ankle Brachial Index (ABI)

Monitors systolic pressure of ankle and brachial arteries with use of a doppler monitor

Ankle figure divided by brachial figure for index number

Diabetics may have arteriosclerosis and toe pressures are required as regular ABI's may be lower then indicate

Transcutaneous oxygen levels (TpO2) have proven to determine adequate circulation equal to or better then Toe pressures

ABIABIIdeally the ABI should be 1.0

Arterial ABI Insufficiency

1.0 - 1.2 none 0.8-1.0 mild0.6 - 0.8 moderate

Below - 0.6 severe

ABI of 0.5 Vascular Consult

re-establishment of an aadequate vascular supply is indicated if feasible

ABI = 0.8 ABI = 0.8 Blood flow in ankleBlood flow in ankle is 80% of that inis 80% of that in the armthe arm

Vascular Assessment

Vascular Lab: Toe pressures more accurate <25 mmHg represent severe occlusion >30 mmHg needed for healing to

occur >45 mmHg in people with diabetesArteriography (diagnosis of by-passable

conditions- surgery)Transcutaneous oxygen pressures ->30%

Arterial Ulcer Characteristics

Trauma – most commonprecipitating event

Usually very painful

Circular or punched out appearance

Painful if leg elevated

Arterial Ulcer CharacteristicsArterial Ulcer Characteristics

Usually on distal areas of foot-toe tip, between digits, over bony prominences or other areas d/t trauma

Arterial Ulcer CharacteristicsArterial Ulcer Characteristics

Wound bed - necrotic tissue (black or yellow) or pale greyish/pink granulation base

Little exudate, dry and necrotic

Surrounding tissue pale or mottled

Determine Potential for HealingDetermine Potential for Healing

Assess Patient and Wound for:Assess Patient and Wound for: Blood Supply

Important for wounds of lower extremities

If inadequate:

- moist interactive wound healing is contraindicated

use topical antiseptics

vascular referral to determine if

re-vasculization possible

Management of Arterial Ulcers

Patient History

Treat the cause

medical consult

surgical consult (vascular)

surgery: restoration of adequate blood supply

Arterial by-pass ( autogenous vein or prosthetic graft)

Angioplasty

Interventions to MaximizeBlood Flow – Treat the Cause

Smoking cessation (causes vasoconstriction)

Warm environment(socks, avoid drafts)

Exercise (as tolerated)

Pain Management (pain causes vasoconstriction)

Elevation of leg contraindicated

Legs at rest should be in neutral position

Management of Arterial Ulcers

Avoid treatments that interfere with arterial flow:

whirlpool sharps debridement compression therapy restrictive footwear elevation of limb above heart levelManagement of Co-morbid diseases(diabetes)Optimal nutrition

Maintain walking with rest periods when pain occurs

Treat for pain around the clock

Manage exudate and odour

Position bed so feet lower then heart

Treat infection – continual assessment for signs of infection – change in pain -change in exudate appearance -change in odour - change in client behaviour withdrawn, decreased appetite, restlessness

Management of Arterial Ulcers

Management of Client Concerns Communicate Fears – provide support

Family/Client education

Independence with wound care when possible

Maintain self esteem through activity and self care

Understanding in regards to pain

Maintain Mobility

Alternative Therapies -relaxation

Treat the Wound Goal – Prevent/treat Infections and

Avoid/Delay Amputation

Moist healing only if adequate blood supply

to heal

Keep area clean & dry if not adequate blood supply to heal

Avoid debridement

Use Povidone iodine to paint wound

If wound wet consider a topical antimicrobial

Assess & treat for infection if needed

Arterial disease Signs of adequate blood supply?

a) Feet warm to touch, pulses presentb) ABI < 0.6c) Colour bluish hued) Hairless legs (culture sensitive) e) all of the above

Arterial Ulcers are painful when legs hang down?

True

False

Arterial ulcers characteristics consist of all except

a) punched out in appearance

b) distal extremities

c) wound base deep red colour

d) pain with elevation

ABI and Toe Pressure assessments determine the amount of venous pressure.

True

False

Which photo shows a arterial ulcer?

A B C D

Group Discussion

What have you seen in your practice?

What was the hardest element of treatment?

What was the most difficult element for the patient?

What were the solutions implemented or tried?

Questions?

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Venous Leg

Ulcers

Leg Ulcer Epidemiology

According to the Canadian Medical advisory Secretariat (MAS),2006 as cited by Burrows et al

prevalence of lower limb ulcers 0.12%-0.32% in general population

approximately 50,000 to 500,000 Canadians with leg ulcers

most people with venous leg ulcers were over the age of 65 and nearly 75% had 3 or more medical conditions (Harrison et al, 2005)

>2/3 had ulcers for many months, ½ affected population had leg ulcer history that spanned 5 – 10 years

estimated cost of 192 people receiving treatment costs $1 million in nursing care and $260,000 in supplies annually

Leg Ulcer Epidemiology

Venous Leg Ulcers1994 survey of people with venous ulcers

81 % adverse effect on mobility

56% spent up to 8 hours per week on ulcer care

68% negative emotional impact, including fear, social isolation, anger,depression, negative self esteem

cost per patient $40,000 - $90,000

Venous Hypertension - Etiology

Valve dysfunction (deep,perforators,superficial)Obstruction from complete or partial blockage of

the veins( DVT)Failure of calf muscle pump function ( decreased

activity)Previous varicose vein surgeryPrevious DVTCongenitalIncreased abdominal pressure (morbid obese,

pregnant)

Venous DrainageVenous Drainage

Deep venous system - under muscle fascia

Superficial venous system - close to skin (greater & lesser saphenous system)

Perforator or communicating veins - join deep venous system & superficial venous system

Venous DrainageVenous DrainageOne way valve system - prevents backward flow of blood

Calf muscle pump - calf muscles contract & squeeze venous blood upward toward the heart need to walk from heel to toeor flexion and extension of ankle beyond 45 degrees

Superficial

Perforator

Deep

Normal

Valves

Incompetent

Valves

Venous Stasis DiseaseRisk Factors

Family History

Obesity

Pregnancy

Occupations that require long hours of standing or sitting

History of: DVT,Leg injury, Varicose Veins or vein

stripping

Venous Stasis Ulcer Diseaseunderlying etiologic factors

Sustained venous hypertension due toValvular dysfunction

Obstruction

Calf muscle pump failure causes localized ischemia due to edema

Clinical Features & Diagnosis

Dilated long Saphenous veinEdema (weeping exudate) worse at the end

of the dayStasis Dermatitis (itchy/dry)Hemosiderin & Melanin deposition (brown

skin staining)Lipodermatosclerosis (woody appearance)Atrophic blanche (white scars)Pain or ache (worse with dependency,

relieved by elevation, worse at end of the day)

Contributing Factors for progression to ulceration

Trauma

Infection

Edema

Malnutrition

Immobility

Assessment & Diagnosis

Complete history (medical and social)

Wound assessment

Vascular Assessment

Investigations

HistoryMedical history – cardiac or pulmonary disease

including CABG

Assess history for:

swelling at the end of the day

varicose veins/ vein stripping, abdominal surgeries, DVT

previous ulcers/treatments

lower leg trauma

prolonged standing

compression treatments

Wound Characteristics

Rapid development

granulating wound base

(may be necrotic initially) red base in colour

Jagged/irregular wound edges – shallow

located above medial or lateral malleoloi

(gaiter area) or on anterior tibial area – lower 1/3 of calf

Wound CharacteristicsEdema

Exudate is usually copious & serous

Peri- wound skin may have dermatitis, hyperemia, maceration, hyper pigmentation, & thickening

Feet warm with palpable pulses

Pain or ache – relieved by elevation

May be complicated by bacterial infection

Treat the Cause Treat the Cause Underlying PathologyUnderlying Pathology

Timely identificationTimely identification of people at risk

ElevationElevation - reduces Edema/venous pressure

Maximize mobility Maximize mobility - consult rehabilitation experts

CompressionCompression - the corner stone of treatment

Weight managementWeight management

Skin careSkin care

Calf Muscle Pump ExercisesROM

Compression

ABI > 0.8 – full compression

ABI 0.6-0.8 – lower (mild to moderate compression) consult advanced wound clinician

ABI, < or = 0.5 no compression – refer to vascular surgeon

Jobst Sigvaris

Compression

Contraindicated if arterial disease is present

Patients with diabetes may have elevated ABI's due to calcified arteries – toe pressure needed by

vascular lab or subcutaneous oxygen

Compression is not for use in acute CHF, DVT, or infection

Underlying PathologyManagement

Compression therapy

Compression bandages

Intermittent pneumatic compression devices

Modified compression

Compression garments – once edema controlled

Clarification of Compression Bandages

Elastic

pressure characteristics example

Low single layer tensors

Moderate single or double Tubigrips

High Long Stretch ProGuide

High Four Layer Profore

How To Measure Fit

STEP 1: Measure the circumference of your ankle. Measure around the narrowest part of your ankle above the ankle bone. Record this measurement...

STEP ONE

Measure to Fit

STEP 2: Measure the circumference of your calf. Measure around your calf at it's widest part. Record this measurement...

STEP TWO

Measure to Fit

STEP 3: Measure the length of your calf. Measure from the floor to the bend in your knee. Record this measurement...

STEP THREE

Measure to Fit

STEP 4: Measure the circumference of your thigh. Measure around the widest part of your thigh just below your gluteal fold. Record this measurement...

STEP FOUR

Measure to Fit

STEP 5: Measure the length of your thigh. Measure from the gluteal fold to the floor. Record this measurement...

STEP FIVE

Jobst Stocking Measuring Scale

STEP 6: Measure around your hips. Locate the widest part of your hips or waist and measure all the way around

Four-layer bandage for Four-layer bandage for sustained sustained graduatedgraduated compression compression

natural padding bandage light conformable bandage

light compression bandage flexible cohesive bandage

S S

8 S

S = spiral8 = figure 8

•Apply all elastic layers at half-stretch•Change q 7 days

1 2

3 4

Profore LiteProfore Lite

Layers 1,2,4Layers 1,2,4

T.E.Ds

T.E.D. Anti-embolism stockings are not the same as support stockings or compression hose. Yes, TED Stockings do have graduated compression to speed blood flow. TED stockings are for the non-ambulatory convalescing person to prevent blood clots.

“T.E.Ds are for bed” compression hosiery is for life Samson & Showalter,1996

Graduated Compression Therapy

Reduces venous hypertension

Improves calf muscle pump

Increases venous return to the heart

Increases removal of Fibrin

Decreases edema

Decreases distension of superficial veins

Classification of CompressionBandages systems (inelastic)

Pressure Characteristic Example

Low flexible cohesive RoloFlex or Padding Coban & cast

padding

Moderate Zinc Oxide bandage Duke Boot & cohesive Velcro system Circaid

Moderate short stretch system Comprilanto High

Compression StockingsCompression StockingsPrevention & AftercarePrevention & Aftercare

4 % recurrence in people who wore good compression stockings.

79% recurrence in people who did not wear good compression stockings.

Any level of compression better then no compression

Teaching is the corner stone of adherence May need tools to assist in applying stockings

Compression hosiery for life

(Samson & Showalter, 1996)

Compression Stockings

Dress support hose – 8.5 mmHg – prominent veins without edema

Class I-20-30 mmHg – treat varicose veins or mild edema

Class II – 30-40 mmHg – recommended to treat more severe varicosities or moderate edema

Class IV - >60 mmHg – for severe venous insufficiency

Level of compression depends on severity of venous hypertension

Compression Stockings

Devices to assist with application rubber gloves nylon or silk sock zipper inserts in the back

Action compress dilated superficial veins

Useremove stockings & bath at bedtime – moisturise

legs -re apply early in AM

2 pairs of stockings should be purchased

may need replacement every 6 months

Summary

Some compression is superior to no compression

high compression is superior to low compression in the absence of significant arterial disease

no clear difference in the effectiveness of the different types of compression stockings

Fletcher et al. 1997

Increased use of correctly applied compression system should be promoted

Elastic systems have an advantage over inelastic systems

Summary

Fletcher et al. 1997

Patient Education

Reduce weight if necessary

Avoid prolonged standing or sitting

walk/calf muscle pump exercises

Elevate feet above level of heart frequently during the day

Periodic reminders of treatment plan for

prevention

Patient EducationOptimum treatment of all co-morbid conditions

Avoid tight bands of clothing around legs

Good skin care – use of emollients

Venous ulcer reoccurance = 72%

Wear compression for life

Treat the WoundIrrigate – 30 ml syringe with cathlon 18 gauge

Support debridement – autolytic/surgical pain management

Rule out or treat infection

Apply dressing that supports moist wound environment

Absorb excess exudate

Appropriate Dressings

Foams

Calcium alginate

Hydrocolliods

Hydrogels

Transparent adhesive dressing

Zinc oxide bandages are an alternate primary layer for use over the dressing alone or under compression bandage

If Conservative Therapy Unsuccessful.....

Surgery InterventionGrafting Pinch grafting Split thickness (disadvantage – donor site

painful & difficult to heal) Biological skin substitutes Ligation and Stripping Arterial surgery for mixed & arterial

disease Biopsy to rule out more unusual causes of

ulceration <10% of venous ulceration are refractory

to medical management

Peripheral Vascular Disease Peripheral Vascular Disease (Ischemia)(Ischemia)

Impairs viability of skin Inhibits/prevents wound healing

ISCHEMIC FOOT ULCERISCHEMIC FOOT ULCER

This patient has previously had most of the toes of this foot removed because of gangrene but has failed to heal one of the amputation sites due to persistent ischemia which

originated in the calf arteries

MixedVenous & Arterial

Coexisting illnesses

Optimal Management

ArterialInsufficiency

VenousReflux

Differential Diagnosis

Venous & arterial insufficiency coexist in about 20% of patients

Prior to the application of compression, an arterial assessment must be done (ABI,Toe Pressures,Transcutaneous Oxygen)

If compression is applied to a limb with impaired arterial blood supply serious damage can result

Mixed Arterial/Venous UlcerManagement

Address limb threatening disease – maximize flow (surgical consult)

Pain control

Passive control of leg edema position limb at heart level modified compression – Tubigrips

Prevent infection topical antiseptics

Compression Therapy

Level Etiology Compression

0.8 – 0.9 Venous High

0.5-0.8 Mixed Modified (low)

Less then Arterial None

Guidelines for interpretation of ABI & compression therapy

Arterial & Venous Ulcer

Treat the cause arterial venous mixedTreat the Wound

moist wound healing (if adequate blood supply to heal)

Treat the patient

pain, compliance, adherence to treatments, nutrition, Life style changes, & follow up

Type of vascular disease needs to be

known prior to compression?

True

False

Mixed disease means:

a) venous & arterial flow diminished

b) client has multiple co-morbid illness plus a ulcer

c) a ulcer on the plantar foot surface is present with Hemosiderin staining

d) no pain with elevation or hanging of feet

Hemosiderin staining is:

a) a large bruise to lower legs from DVT

b) dull woody appearance on lower leg caused by edema

c) white spot on the skin that does not blanche

d) brown staining to lower leg associated with venous disease

Compression is a treatment option for mixed disease

a) all the time

b) according to ABI

c) only if palpable edema present

d) never

Diagnosis and why

Potential cause

Treatment recommendation

78 year old male

recent widow, no children

mixed farming

early spring

quit smoking 1 year ago

hauls water – no well

If lower leg is red but fades with elevation what could this indicate?

a) arterial disease

b) phlebitis

c) Cellulitis

d) vascular disease

Questions?

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