arterial ulcers by joel arudchelvam

Dr Joel ArudchelvamConsultant Vascular and Transplant Surgeon

Ulcer /Wound / Abrasion

A full thickness breach in the continuity of the skin

Partial thickness (epidermis) - Abrasion

Skin Anatomy

Wound healing

4 stages Haematoma formation Inflammation/ debridment Proliferation Remodelling / maturation

Inflammatory Stage Within 24 hours neutrophils, and macrophages migrate to wound

Characterized by redness, heat, pain and swelling

remove organisms ,dead tissue, secrete cytokines and growth factors for proliferative stage

approximately 4 to 5 days

Proliferative PhaseGranulation • Fibroblasts - collagen , proteoglycans• New capillaries

Growth factors – secreted by macrophages – •PDGF, TGF , VEGF

Epithelialization • Crosses moist surface

Remodelling

Reorganization of collagen (type III to

type I)

MMPs and TIMPs

Increase in tensile strength

Non healing ulcer / chronic ulcers

Ulcers not showing signs of healing by 6 weeks are called chronic ulcers.

In non healing ulcers…

Prolonged pro-inflammatory phase Persistent elevation of pro inflammatory

cytokines - Inhibits action of fibroblasts and epithelial cells

High MMPs, reduced TIMPs

Reduced VEGF – esp in CLI

Causes for non-healing ulcers.

1. Local causes-Repeated trauma-Presence of foreign body / slough-ongoing infection / osteomyelitis 

2. Regional causes

-Venous-Arterial insufficiency-Neuropathic

3. Systemic causes -Diseases - diabetes mellitus, renal failure, etc.- Drugs - immunosuppressives, cytotoxic-Nutritional deficiencies - protein, Hb, vitamin and mineral

Causes for non-healing ulcers.

1. Local causes-Repeated trauma-Presence of foreign body / slough-ongoing infection / osteomyelitis 

2. Regional causes-Venous

-Arterial insufficiency-Neuropathic

3. Systemic causes -Diseases - diabetes mellitus, renal failure, etc.- Drugs - immunosuppressives, cytotoxic-Nutritional deficiencies - protein, Hb, vitamin and mineral

Occlusive Arterial Disease - OADCauses

Atheromatous Risk Factors

Smoking Diabetes Hypertension Hyperlipidemia Advanced age

Inflammatory Buergers Takayasu Vasculitis

Presentation

• Claudication

• Rest pain

• Ulcer

• Gangrene

Fontaine classification

Stage Symptoms I Asymptomatic II Intermittent claudication

IIa Pain-free, claudication walking >100 m IIb Pain-free, claudication walking <100 m

III Rest pain IV ulcer / gangrene

Stage III and IV “critical limb ischaemia”

Ulcer

In distal part of limb (forefoot or toes)

Dry Painful

Features OAD

Atrophic thin leg Lack of hair Shiny skin Brittle nails Absent pulse Cold Associated

gangrene

Natural history of ischaemic ulcers

Ankle Brachial Pressure Index (ABPI) ABPI{Leg} = P{Leg} / P{Arm}

P leg - blood pressure of dorsalis pedis / posterior tibial arteries

P Arm - brachial systolic blood pressure

Less than 0.9 is abnormal ABPI < 0.5 is better predictor of non

healing

Imaging

USS + Doppler – duplex scan

CT/MR Angiography

Duplex scan USS + Doppler

Can visualise the vessels, stenosis, plaques

Can see the flow and its quality

Non invasive Good for infrainguinal

vessels Abdomial vessels –

obscured by bowel gas

Angiography CT angiography

Catheter angiography

CT Angiography

NORMAL

Conventional angiography / DSA

Treatment for chronic ulcers

Local

Regional

Systemic

Treatment for chronic ulcers Local Wound toilet

o Process of removal of slough, dead tissue, foreign bodies and draining pus.

o Following a wound toilet the wound base is made suitable for future granulation and epithelialisation.

o Ischaemic ulcer – if infected / wet – wound toilet before revascularization / otherwise (dry scab, dry gangrene ) revascularization and then wound toilet

Management

Indications for revascularisation

1. Disabling claudication

2. Rest pain

3. Tissue loss

(Fontaine stage IIB, III, IV)

Management

Surgical

1.Bypass2.Endarterctomy

Endovascular1.Angioplasty and/2.Stenting

Amputation

Angioplasty and/ Stenting

Bypass

Conduits / Grafts

1. Autogenous

Reversed Saphenous v ein Graft ( RSVG)2. Synthetic

PTFE

polyester(DACRON)

Treatment for chronic ulcers Systemic causes

Correct anaemia, vitamin deficiency and other nutritional deficiencies.

Optimization of underlying comorbidities.

Role of antibiotics in wound - indicated only in patients with evidence of local or systemic infection.

Wound dressings

The material which is applied to the surface of the wound to cover it is called a dressing. 1ry – dressing which touches the wound 2ry – dressing used to cover the primary

dressing

Ideal wound dressing

Characteristics Provide a protective cover Maintain moisture Absorb exudates Does not induce pain or itching Easy to remove / does not adhereAllows gaseous exchange Cheap Freely available

Types of Wound Dressings

Gauze dressings Tulle Hydrocolloid dressings Hydrogel dressings Alginate dressings Foam dressings Transparent film dressings Etc.

Gauze

Cheap Freely available

Dry Painful on removing Damages epithelium

Tulle

Cheap Freely available Does not adhere Does not damage

epithelium Easy removal

E.g : Vaseline

Hydrocolloid Dressings•Made up of pectin based material

•Come in various shapes and sizes

Hydrogel DressingsMade up of water in a polymer to maintain moistureused in dry wounds

Silver Dressings Slow release of silver ion Antimicrobial to reduce bio burden of

wound e.g. Acticoat, Biatin Ag, Atruman Ag

Vacuum assisted closure VAC

Vacuum assisted closure VAC

Vacuum assisted closure VAC Macrostrain - stretch that occurs when

negative pressure is applied.

Draws wound edges together Provides direct wound contact Removes exudate and infectious materials

Microstrain - micro deformation at the cellular level Reduces edema Promotes granulation tissue

by facilitating cell migration and proliferation

Vacuum assisted closure VAC Indications for use

Large wounds Cavities Large amount of exudate

When to change dressings

When there is an indication to change Soaking Pain Need to inspect

Discuss with doctor before changing

Avoid

• Do not tie gauze bandage tightly around limbs, digits – causes ischaemia

• Use – plaster , crepe instead

Avoid in chronic wounds

Iodine (Betadine) Hydrogen peroxide Other toxic agents

ARTERIAL ULCERS

Recognise OAD Refer appropriately

Assess fitness for intervention Correct the occlusion

Correct systemic factors / co morbidities

Keep wet Do not apply tight dressings

Thank You