What is the best treatment for an arterial ulcer?

Best Treatment for Arterial Ulcers

The primary treatment for arterial ulcers is revascularization to improve blood supply to the affected area, either through endovascular procedures or open surgical reconstruction, followed by appropriate wound care. 1, 2

Diagnosis and Assessment

Before treatment, proper assessment is crucial:

• Check for signs of peripheral arterial disease (PAD):
  • Absent pedal pulses
  • Ankle-Brachial Index (ABI) <0.9
  • Toe-Brachial Index (TBI) <0.7
  • Toe pressure <30 mmHg
  • Transcutaneous oxygen pressure (TcPO₂) <25 mmHg 3

Treatment Algorithm

Step 1: Urgent Vascular Intervention

• Urgent revascularization is indicated when:
  • Toe pressure <30 mmHg
  • TcPO₂ <25 mmHg
  • Ankle pressure <50 mmHg or ABI <0.5 1, 3
  • When ulcer shows no signs of healing within 6 weeks despite optimal management 1

Step 2: Revascularization Method

• Endovascular procedures (balloon angioplasty) are preferred first-line treatment due to lower risk of graft infection in patients with open ulcers 2
• Surgical bypass should be considered when:
  • Patient has life expectancy >2 years
  • Autogenous vein conduit is available
  • Anatomy is favorable for bypass 3
• Selection between techniques should be based on:
  • Morphological distribution of PAD
  • Availability of autogenous vein
  • Patient comorbidities
  • Local expertise 1

Step 3: Wound Care Management

• For purely ischemic ulcers without infection:

  • Avoid debridement until blood flow is restored 3
  • Maintain moist wound environment 3
  • Provide protective covering 1
  • Avoid footbaths (risk of maceration) 3

• For infected arterial ulcers:

  • Cleanse and carefully debride necrotic tissue
  • Start empiric antibiotics targeting common pathogens
  • For deep infections, consider urgent surgical drainage 1, 3

Step 4: Offloading and Pressure Relief

• Reduce mechanical stress on the wound
• Consider appropriate offloading devices based on ulcer location 3
• Instruct patient to limit standing and walking, use crutches if necessary 1

Step 5: Advanced Therapies

• Consider negative pressure wound therapy (NPWT) for non-healing wounds after revascularization 3
• Select dressings based on exudate control, patient comfort, and cost 3

Risk Factor Modification

Aggressive cardiovascular risk management is essential:

• Smoking cessation
• Treatment of hypertension
• Diabetes control (optimal blood glucose <8 mmol/L)
• Statin therapy
• Antiplatelet therapy (low-dose aspirin or clopidogrel) 1, 3

Important Considerations

• Avoid revascularization when the risk-benefit ratio is unfavorable (severe frailty, short life expectancy, poor functional status, unsalvageable foot) 1
• Even severely ischemic ulcers can heal without revascularization in approximately 50% of cases, but this should not delay appropriate intervention 1
• The goal of revascularization is to restore direct flow to at least one of the foot arteries, preferably the artery supplying the anatomical region of the wound 1
• Pharmacological treatments to improve perfusion have not been proven beneficial for arterial ulcers, though cilostazol may improve walking distance in patients with intermittent claudication 1, 4

With appropriate revascularization and wound care, most arterial ulcers will progress to healing unless there are complicating factors 2, 5. Early intervention is critical to prevent progression to gangrene and potential limb loss.