What is the initial workup and management for a patient presenting with multiple ischemic ulcers on the lower extremities?

From the Guidelines

The initial workup for a patient with multiple ischemic ulcers on the lower extremities should include a comprehensive vascular assessment, including ankle-brachial index (ABI), duplex ultrasound, and possibly angiography to determine the extent of arterial insufficiency, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

Initial Workup

The workup should prioritize the evaluation of the entire lower extremity arterial circulation, with detailed visualization of below-the-knee and pedal arteries, as suggested by the IWGDF guidance on the diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers in diabetes 1. This comprehensive assessment will guide the management approach, focusing on optimizing blood flow to the affected areas.

Management Approach

Management begins with optimizing blood flow through revascularization procedures when indicated, such as angioplasty, stenting, or bypass surgery. The aim of revascularization is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, with the goal of achieving a minimum skin perfusion pressure ≥40 mmHg, a toe pressure ≥30 mmHg, or a TcPO2 ≥25 mmHg, as recommended by the IWGDF guidance 1.

Wound Care and Risk Factor Modification

Wound care is essential and includes:

• Regular debridement of necrotic tissue
• Infection control with appropriate antibiotics
• Moist wound healing with appropriate dressings changed every 1-3 days Risk factor modification is crucial, including:
• Smoking cessation
• Diabetes control (target HbA1c <7%)
• Blood pressure management (goal <140/90 mmHg)
• Cholesterol reduction with statins (such as atorvastatin 40-80 mg daily) Antiplatelet therapy with aspirin 81 mg daily or clopidogrel 75 mg daily should be initiated, as supported by the ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease 1.

Patient Education and Follow-Up

Patients should be advised to:

• Avoid pressure on the affected areas
• Elevate legs when sitting
• Use specialized offloading footwear Regular follow-up every 1-2 weeks is necessary to monitor wound healing and adjust treatment, ensuring a comprehensive approach that addresses both the underlying vascular insufficiency and promotes wound healing while preventing complications like infection and further tissue loss, in line with the recommendations from the 2024 ESC guidelines 1.

From the Research

Initial Workup

• The initial workup for a patient presenting with multiple ischemic ulcers on the lower extremities involves a thorough patient history and physical assessment to discriminate between ischemic ulcers caused by arterial disease and other types of ulcers 2.
• A general exam should be performed to look for problems relating to lungs, heart, and nervous system, and a focused exam of the affected extremities and arterial pulses should be conducted 2.
• Vascular laboratory findings, such as ankle systolic pressure and calculated ankle/brachial index, can help confirm a diagnosis of arterial ischemic ulceration 3, 2.

Diagnosis

• Arterial ulcers occur because of inadequate perfusion of skin and subcutaneous tissue at rest, often due to arterial occlusive disease, which can lead to claudication, rest pain, and gangrene, in addition to localized ulceration 3, 2.
• A diagnosis of diabetic foot and diabetic lower extremity arterial occlusion can be made based on a combination of patient history, physical exam, and imaging studies such as X-ray, color Doppler ultrasound, and computed tomographic angiography (CTA) 4.
• The diagnosis of arterial ulcers should be differentiated from other types of ulcers, such as venous leg ulcers, diabetic foot ulcers, pressure ulcers, and vasculitis ulcers 3, 2, 5.

Management

• The primary treatment of arterial ischaemic ulcer is to increase blood supply to the affected area, primarily by endovascular treatment or open arterial reconstruction 3.
• Endovascular treatment, such as balloon angioplasty, is the method of choice because of graft infection risk in patients with open ulcers 3.
• Medical options, including good wound and supportive care, can be considered if interventional procedures are not possible, and pharmaceutical interventions such as cilostazol may be effective in promoting wound healing 6.
• A combination of treatments, including antiplatelet and anticoagulation therapy, vasodilation, local debridement, and ultrasonic debridement, may be necessary to achieve wound healing 4.
• Autologous platelet-rich gel therapy and topical β adrenergic receptor blocker may also be effective in treating refractory ischemic diabetic foot ulcers 4.