What is the management of arterial ulcers?

Management of Arterial Ulcers

The management of arterial ulcers requires a multidisciplinary vascular team approach focusing on revascularization to restore blood flow, along with aggressive cardiovascular risk management, wound care, and infection control to prevent limb loss and reduce mortality. 1

Diagnosis and Assessment

• Evaluate the entire lower extremity arterial circulation with detailed visualization of below-the-knee and pedal arteries to determine the extent of peripheral artery disease (PAD) 1
• Measure ankle systolic pressure and ankle-brachial index (ABI); an ABI <0.9 indicates PAD, while ABI 0.9-1.3, toe brachial index ≥0.75, or triphasic pedal Doppler arterial waveforms largely exclude PAD 1
• Consider urgent vascular imaging when toe pressure is <30 mmHg, transcutaneous oxygen pressure (TcPO₂) <25 mmHg, ankle pressure <50 mmHg, or ABI <0.5 1
• Differentiate neuroischemic ulcers (painful, absent pulses, irregular margins, commonly on toes, pale/cyanotic appearance) from neuropathic ulcers (painless, normal pulses, punched-out appearance, often on sole or metatarsal head) 1

Revascularization

• The primary treatment for arterial ulcers is revascularization to restore direct blood flow to at least one foot artery, preferably the artery supplying the anatomical region of the wound 1, 2
• The goal of revascularization is to achieve minimum skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO₂ ≥25 mmHg 1
• Consider both endovascular techniques and bypass surgery based on:
  • Morphological distribution of PAD
  • Availability of autogenous vein
  • Patient comorbidities
  • Local expertise 1
• For aorto-iliac disease, endovascular approach is the first choice, with surgery reserved for extensive obstructions or unsuccessful endovascular procedures 1
• For femoro-popliteal disease, select revascularization strategy according to lesion complexity; if bypass surgery is chosen, use the shortest possible bypass with saphenous veins 1
• Avoid revascularization in patients where the risk-benefit ratio for success is unfavorable (severe frailty, short life expectancy, poor functional status, bed-bound, or large volume of tissue necrosis) 1

Medical Management

• Provide aggressive cardiovascular risk management including:
  • Smoking cessation support
  • Treatment of hypertension
  • Control of glycemia in diabetic patients
  • Prescription of statins
  • Low-dose aspirin or clopidogrel 1
• Treat infection with appropriate antibiotics; in diabetic or immunocompromised patients, infections tend to be polymicrobial and may require systemic antibiotic therapy 1
• For deep-seated infections, obtain X-ray or MRA to diagnose osteomyelitis, which requires a longer course of antibiotics 1
• Ensure aggressive offloading of mechanical tissue stress to allow wound healing 1
• Lower-limb exercise training is contraindicated until ulcers are healed 1

Wound Care

• Provide optimal wound care with appropriate dressings; while evidence for superiority of specific dressings is lacking, individualized treatments may include:
  • Antimicrobial dressings
  • Silver dressings
  • Honey or iodine-based dressings
  • Platelet-rich plasma
  • Collagen
  • Negative pressure therapy 1
• Assess for venous etiology in mixed ulcers, which may require compression therapy after revascularization 1

Multidisciplinary Approach

• Management by a vascular team including at least a vascular physician, vascular surgeon, and radiologist is recommended 1
• After revascularization, patients should be treated by a multidisciplinary team as part of a comprehensive care plan 1
• For patients with signs of PAD and foot infection, emergency treatment is required as they are at particularly high risk for major limb amputation 1
• Regular surveillance should be performed during subsequent examinations, with thorough inspection of the feet to evaluate for early signs of skin breakdown or ulceration 1

Special Considerations

• Diabetic microangiopathy should not be considered the cause of poor wound healing in patients with foot ulcers 1
• Most arterial ulcers will progress to healing if blood supply is reestablished, but healing may be impaired by complicating factors 2, 3
• In patients with non-healing ulcers despite optimal management for 6 weeks, consider vascular imaging and revascularization regardless of bedside test results 1