Arterial Ulcer – Symptoms, Diagnosis, and Treatment
What is an Arterial Ulcer?
Arterial ulcers, also called ischemic ulcers, are frequently seen by wound care physicians as well as vascular surgeons and limb salvage teams. Approximately 20% of all lower extremity ulcers in high-income countries occur in patients with arterial insufficiency. These wounds can be painful and are typically very difficult to heal. Ischemic wounds may also present as areas of dry gangrene, typically caused by arterial disease of the proximal vessels.
How do Arterial Ulcers Form?
The underlying cause of arterial ulcers is tissue ischemia related to arterial disease or occlusion. Most arterial wounds form on the toes and feet, but they can present on the fingertips as well. It is rare to find a true ischemic ulcer on other anatomic locations.
If the wound is open or ulcerated, there is often a coincident traumatic event prompting the skin opening, such as a bumped toe or friction from a shoe. A small soft tissue infection such as a paronychia can also incite a chronic ischemic ulcer. Dry gangrene is also classified as an arterial wound even though the surface is typically not ulcerated.
The patient’s extremity may show signs of inadequate perfusion including cyanosis of the digits, cool temperature, pain, blisters, pale color, and formation of black eschar or mummified digits. One may also see the so-called blue toe syndrome from acute occlusive vasculopathy.
Causes of Arterial Ulcer
- Embolism, which may be composed of
- Cholesterol, typically originating in the heart or aortoiliac vessels
- Tumor fragmentation with embolism
- Fat, typically the result of long bone trauma or surgical complication
- Foreign objects (device fragments)
Acute Arterial Thrombosis
- The most common cause of thrombosis is atherosclerotic disease. Smoking increases the risk of developing
atherosclerosis by 50%.
- Other causes of acute thrombosis include:
- Sepsis, typically with septic emboli
- Hypotension, decreased cardiac output; often related to sepsis
- Presence of aneurysm or aortic dissection
- Presence of arterial bypass graft
- Autoimmune diseases including vasculitis and coagulopathies such as disseminated intravascular
coagulopathy (DIC) or purpura fulminans
- Presence of malignancy causing hypercoagulable state
- Frostbite, due to formation of ice crystals in the intravascular spaces causing endothelial damage.
- Hyperviscosity or abnormal circulating protein syndromes such as Waldenstrom macroglobulinemia (the most common), cryoglobulinemia or deformations of blood cells.
Peripheral arterial disease. Certain medical conditions increase the risk of chronic arterial disease, including:
- Cardiovascular disease including myocardial infarction and cerebrovascular disease
- Severe cases cause chronic fibrin and protein to move into the soft tissue, resulting in tissue fibrosis and capillary dysfunction. When severe, it can lead to arterial compression and small vessel occlusion.
- Presence of proximal arterio-venous shunt, such as a dialysis access site. This is the most common clinical situation in which one sees ischemia in the fingertips rather than toes.
Symptoms of Arterial Ulcers
The most prominent symptoms of arterial ulcers are the symptoms of the underlying arterial insufficiency. These may include pain with ambulation (claudication) and pain at rest which is relieved with the foot in a dependent position, although this can be masked in a diabetic patient with neuropathy. The skin may have a blue or dark discoloration and may be shiny and pale. The involved area may be slightly cool to the touch. (A truly cold extremity is a surgical emergency.) The patient may have brittle nails as well. Arterial wounds tend to be quite painful. Dry gangrenous toes or feet are typically painless, but the ischemic tissue in the viable part of the extremity may be painful.
Ischemic wounds are typically round, shallow, with a pale tissue bed, and have a “punched out” appearance. There is usually very little exudate. Ischemia may also present as dry gangrene without a specific wound or ulceration. While an ischemic wound may heal with proper intervention, dry gangrene cannot heal. Gangrenous tissue will auto-amputate over time, if it is not amputated surgically.
Diagnosis of Arterial Ulcer
The diagnosis of arterial wounds is made by diagnosing the underlying arterial disorder. The first step in diagnosis is checking for pulses on a physical exam. Decreased or absent pulses suggest arterial disease.
The next step in diagnosis is a Doppler ultrasound. This evaluates the wave forms, flow velocities, toe pressures, and also may be used to calculate the Ankle Brachial Index (ABI). The ABI is a helpful tool in determining the severity of vascular disease.
|ABI >1.2||Incompressible vessels, often seen in diabetic patients. In this situation, the ABI is not considered a meaningful measurement.|
|ABI 0.8-1.2||Not suggestive of any significant disease|
|ABI 0.5 – 0.8||Mild to moderate arterial disease|
|ABI||severe arterial disease|
Patients with significant disease are usually referred to a vascular surgeon; an unremarkable ABI should not preclude this referral if the physician has a high level of suspicion of arterial compromise. These patients often go on to have angiography, whether via computed tomography (CTA) or magnetic resonance imaging (MRA), or a minimally invasive angiogram procedure. Surgical procedures, both percutaneous and open, may be able to correct the cause of the ischemia.
Arterial Leg Ulcer Treatment
The first step in treating an arterial ulcer is to correct the underlying arterial disorder. If arterial perfusion can be corrected, the prognosis for healing is very good. If the arterial disease cannot be corrected, the wound has a low likelihood of healing and may ultimately go on to amputation.
Wounds with Uncorrected Arterial Disease
Patients with arterial disease that cannot be resolved should be treated with care. Unlike almost all other wounds, dry wounds or dry gangrene are not treated with moist wound healing and debridement is typically kept to a minimum. This is one of the only types of wounds that should be kept dry. These sites are typically treated by painting the surface with povidone-iodine solution and leaving it open to air. If the area is susceptible to injury, a dry loose wrap may be applied. Similarly, if the patient states that their pain is improved with the presence of a dressing, a light dry dressing may be used. It is important to remember that dryness is the goal; a dressing designed to maintain a moist wound environment, such as a hydrocolloid or foam dressings, should not be used on a dry stable arterial site.
Debridement of ulcers in a severely ischemic tissue bed is typically not performed unless there is concern for infection, avulsion of tissue, or patient discomfort due to eschar bulk.
Wounds with Corrected Arterial Disease
Patients with corrected arterial disease are treated like other wounds and typically do well. The open wounds are generally managed with a moist wound environment using products such as hydrogel impregnated gauze or gel, leptospermum honey pads or gel, or oil emulsion perforated gauze. There are many other moisture-donating or moisture-preserving products available that may also be appropriate. It is rare for an arterial wound to have sufficient drainage to require a moisture-removing dressing, but in patients with mixed arterial and venous disease a more absorptive dressing may be required.
Patients who smoke should receive smoking cessation assistance. To prevent additional tissue damage, care should be taken to offload and protect areas with wounds.
Some patients with arterial wounds may be candidates for hyperbaric oxygen therapy, although this is not the usual treatment for these wounds. Compression is not performed for arterial wounds, although light compression may be appropriate for some patients who have both arterial and venous disease.
A Word About Wet Gangrene
When the tissue in a gangrenous area becomes moist, it is referred to as wet gangrene. While dry gangrene is considered relatively stable with a fairly low risk of infection, moisture in the tissue increases the permeability to bacteria and the likelihood of infection increases significantly. Wet gangrenous tissue may very quickly become malodorous and overtly infected and can lead to amputation, sepsis, and even patient demise. Wet gangrene should be managed as an urgent, potentially limb- or life-threatening condition.
(Note: For the purpose of this article, the term “wet gangrene” refers only to ischemic nonviable tissue that becomes wet or develops drainage. As used here, this term does not refer to infectious or necrotizing gangrene.)
Patient Actions to Improve Arterial Insufficiency
The single most important thing a patient can do to minimize arterial insufficiency is to stop smoking. A study that evaluated vascular surgery patients found that smokers who quit were less likely to have died within five years of their procedure than those who continued to smoke (14% vs 31%). Their amputation rates were also significantly lower, with 81% of nonsmokers having no amputations vs only 60% of smokers.
While e-cigarettes are less harmful overall due to the lack of debris and toxins from burned tobacco, they still contain ultrafine particles, carcinogens, heavy metals, and volatile organic compounds. Nicotine-related vascular damage remains the same.
A recent study evaluated the effect of e-cigarettes and smoking on postoperative healing. They found no benefit from e-cigarettes over smoking when looking at failed healing and development of wound necrosis. While it is true that there are some benefits to electronic cigarettes, they certainly are not damage-free.
Other patient behaviors that reduce risk of arterial disease include regular exercise and maintaining a healthy body weight. Diabetic patients with good glucose control are also at somewhat lower risk than those with poor glucose control.
Ischemic wounds are areas of tissue damage caused by inadequate blood flow, with or without incidental trauma or infection. They may manifest clinically as open wounds or dry gangrene. While wound care is important for arterial ulcers, the most important factor for healing is resolution of the underlying arterial disease.
Arterial occlusion or insufficiency may be due to chronic or acute causes. The most common cause overall is atherosclerotic disease. Patients who smoke and those who have diabetes are at higher risk for arterial disease.
Treatment of the arterial wound involves treatment of the underlying vascular disease. Wound care is determined by both the severity of the ischemia as well as the condition of the wound bed.
Are arterial ulcers wet or dry?
It is unusual for arterial ulcers to have large amounts of drainage. Most are dry or have light exudate. Arterial wounds in patients with mixed arterial and venous disease may have more exudate.
Are arterial ulcers painful?
Yes, these wounds tend to be painful. However, diabetic patients with neuropathy may have very little discomfort.
How can you tell the difference between arterial, venous and diabetic ulcers?
These three types of wounds differ in terms of their anatomic location, patient symptoms and medical history, pain, clinical appearance, and exudate. While there may be some contribution from more than one etiology – arterial wounds in a diabetic patient, for example – there is typically one primary cause.
Where are arterial ulcers usually found?
Arterial ulcers are most common on the toes, followed by anywhere on the feet/ankles. In certain cases, like dialysis shunts or certain disease states, they may be found on the fingertips. There are instances of arterial wounds in other locations, but these are rare.
Are arterial ulcers deep or shallow?
Arterial wounds are typically shallow in appearance. The exception to this is an area of dry gangrene that auto-amputates or is surgically amputated. Those wounds can be fairly deep.
What causes arterial deficiency?
Arterial insufficiency has many causes, but the most common are atherosclerosis, smoking, and diabetes.
What is the differential diagnosis of arterial ulcer?
When one suspects an arterial ulcer, an investigation of the adequacy of arterial flow is performed. This provides information that fairly definitively defines the diagnosis. Other possible causes include diabetic wounds, atypical infections, autoimmune wounds, and other less common causes. With all of these etiologies, however, one should assess the adequacy of tissue perfusion to rule out arterial insufficiency as a contributing etiology.
Resources and References
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Published online 2020 Jan 20. doi: 10.1002/14651858.CD001836.pub4
Dressings and topical agents for arterial leg ulcers
University of Edinburgh, Usher Institute, Teviot Place, EdinburghUK, EH8 9AG
The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon TyneUK
Cathryn Broderick, Email: email@example.com.
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Cigarette Smoking and Progression of Atherosclerosis. The Atherosclerosis Risk in Communities (ARIC) Study
George Howard, DrPH; Lynne E. Wagenknecht, DrPH; Gregory L. Burke, MD, MS; et alAna Diez-Roux, PhD; Gregory W. Evans, MS; Paul McGovern, PhD; F. Javier Nieto, MD, PhD; Grethe S. Tell, PhD; for the ARIC Investigators
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Volume 60, Issue 6, December 2014, Pages 1565-1571
Smoking cessation is associated with decreased mortality and improved amputation-free survival among patients with symptomatic peripheral artery disease
Author links open overlay panelEhrin J. Armstrong MD, MS a, Julie Wu BS b, Gagan D. Singh MD b, David L. Dawson MD c, William C. Pevec MD c, Ezra A. Amsterdam MD b, John R. Laird MD b
- Association of Electronic Cigarette Vaping and Cigarette Smoking With Decreased Random Flap Viability in Rats
Zaroug Jaleel, and
Published Online:17 Jan 2019https://doi.org/10.1001/jamafacial.2018.1179