What are the causes and treatments of Chronic Arterial (Artery) ulcers?

From the Guidelines

Chronic arterial wounds require prompt medical attention and a comprehensive treatment approach, with the primary recommendation being to address the underlying arterial insufficiency through revascularization procedures such as bypass surgery, angioplasty, or stenting when appropriate, as supported by the most recent guidelines 1.

Key Principles of Treatment

The treatment of chronic arterial wounds involves several key principles, including:

• Maintaining a clean, moist environment using non-adherent dressings like silicone-based products or hydrocolloids, changed every 1-3 days depending on exudate levels
• Pain control, often requiring medications such as acetaminophen 500-1000mg every 6 hours or tramadol 50-100mg every 6 hours as needed
• Infection prevention, with topical antimicrobials like silver-containing dressings used prophylactically, and systemic antibiotics (such as amoxicillin-clavulanate 875/125mg twice daily for 7-10 days) reserved for active infections
• Patients should maintain legs in a dependent position to improve arterial flow, avoid pressure on the wound, stop smoking immediately, and control comorbidities like diabetes (maintaining HbA1c below 7%) and hypertension

Advanced Wound Therapy

Advanced wound therapy can play a role in the treatment of chronic arterial wounds, particularly when there is a failure to show a reduction of 50% or more after 4 weeks of appropriate wound management, as noted in the guidelines 1.

Revascularization

Revascularization procedures are a crucial component of treatment, with the goal of restoring adequate circulation to the affected area, as emphasized in the guidelines 1 and 1.

Multidisciplinary Approach

Treatment of chronic arterial wounds is best managed in a multidisciplinary setting, involving a team of healthcare professionals with expertise in wound care, vascular surgery, and other relevant specialties, as supported by the guidelines 1.

Patient Education

Patient education is essential, with patients needing to be informed about the importance of maintaining a healthy lifestyle, avoiding smoking, and controlling comorbidities, as well as the need for regular follow-up and monitoring, as noted in the guidelines 1.

Regular Debridement

Regular debridement of necrotic tissue is necessary, but should be performed cautiously to avoid further tissue damage, as supported by the guidelines 1.

Restoration of Adequate Circulation

Restoration of adequate circulation is the cornerstone of successful treatment, and without addressing the underlying vascular insufficiency, even the best local wound care will likely be ineffective, as emphasized in the guidelines 1.

From the Research

Chronic Arterial Wounds

• Chronic arterial wounds are a type of chronic wound that does not progress through a normal, orderly, and timely sequence of repair 2
• They are common and are often incorrectly treated, highlighting the need to implement wound prevention and treatment guidelines 2
• Physical examination alone can often guide the diagnosis, and all patients with a nonhealing lower extremity ulcer should have a vascular assessment 2

Diagnosis and Treatment

• The mainstay of treatment is the TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound 2
• Patients with arterial ulcers should be immediately referred to a vascular surgeon for appropriate intervention 2
• Treatment of arterial ulcers involves addressing the underlying arterial insufficiency, and cilostazol has been shown to be effective in promoting healing of wounds when arterial insufficiency is present 3

Management and Prevention

• Multidisciplinary wound care teams have been shown to significantly increase wound healing and reduce the severity of wound-associated pain and the required daily wound treatments compared to persons not managed by a wound care team 4
• There is insufficient evidence to conclude that antiseptics or topical antibiotics improve or heal pressure ulcers and venous leg ulcers more effectively than nonmedicated dressings 5
• Systemic antibiotics are used for patients with nonhealing wounds when the clinical infection is not improving with antiseptics or topical antibiotics 5

Pharmacotherapy

• Topical wound therapies have unclear benefits for patients with pressure ulcers, venous leg ulcers, and arterial ulcers 5
• Oral pentoxifylline has been shown to be more effective than placebo or no therapy in improving and healing venous leg ulcers 5
• Nutritional supplementation has not been clearly shown to prevent or manage chronic ulcers 5