Management of Arterial Ulcers
The cornerstone of arterial ulcer management is revascularization to restore direct blood flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, with the aim of achieving minimum perfusion parameters (skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO2 ≥25 mmHg). 1
Diagnosis and Assessment
Vascular Evaluation
- Assess for signs of peripheral arterial disease (PAD):
Risk Stratification
- Urgent vascular imaging and revascularization is indicated when:
- Toe pressure <30 mmHg
- TcPO2 <25 mmHg
- Ankle pressure <50 mmHg or ABI <0.5
- Signs of infection with PAD (particularly high risk for amputation) 1
Treatment Algorithm
1. Restore Skin Perfusion
- Revascularization should be considered in all patients with arterial ulcers and PAD 1
- Consider urgent revascularization with critical perfusion parameters (as above)
- Consider revascularization when ulcer does not improve within 6 weeks despite optimal management 1
- Revascularization technique (endovascular vs. bypass) should be determined by a multidisciplinary team based on:
- Morphological distribution of PAD
- Availability of autogenous vein
- Patient comorbidities
- Local expertise 1
2. Wound Care Management
- Offloading: Reduce mechanical stress on the wound 1, 2
- Debridement: Only debride necrotic tissue in neuropathic ulcers; avoid debridement in purely ischemic ulcers without signs of infection 1
- Infection control:
- For superficial infections: Cleanse, debride necrotic tissue, start empiric oral antibiotics targeting S. aureus and streptococci
- For deep infections: Urgent surgical drainage, consider revascularization, initiate broad-spectrum parenteral antibiotics 1
- Moisture balance: Control exudate and maintain moist wound environment 1
- Avoid: Footbaths (contraindicated as they induce skin maceration) 1
3. Cardiovascular Risk Management
- Aggressive cardiovascular risk reduction:
- Smoking cessation
- Treatment of hypertension
- Lipid management (statin therapy)
- Low-dose aspirin or clopidogrel
- Diabetes control (optimal blood glucose <8 mmol/L or <140 mg/dL) 1
4. Follow-up and Monitoring
- Regular wound inspection
- Vascular reassessment if healing is not progressing
- Consider vascular imaging if ulcer does not improve within 6 weeks despite optimal management 1
Special Considerations
Diabetic Patients
- Diabetic patients often have mixed neuropathic and ischemic ulcers ("neuro-ischemic")
- Calcification of arteries may make ABI unreliable; toe pressures or TcPO2 measurements are preferred 1
- Diabetic patients frequently have infra-popliteal disease requiring specialized revascularization approaches 1
Non-healing Ulcers
- If no improvement after 6 weeks of optimal management, consider:
- Reassessment of vascular status
- Vascular imaging (color Doppler ultrasound, CT angiography, MR angiography, or intra-arterial digital subtraction angiography)
- Revascularization even if initial bedside tests were not severely abnormal 1
Common Pitfalls to Avoid
- Do not attribute poor wound healing to microangiopathy in diabetic patients - macrovascular disease is the primary cause of poor healing 1
- Do not debride ischemic ulcers without signs of infection 1
- Do not delay revascularization in patients with critical limb ischemia and infection 1
- Do not rely solely on ABI in patients with diabetes or renal disease due to potential arterial calcification 1
- Do not use footbaths as they cause skin maceration 1
Most arterial ulcers will progress to healing if adequate blood supply is reestablished, making revascularization the primary treatment goal for these patients 3.