Arterial Ulcer


Arterial occlusion

 Peripheral arterial disease (arteriosclerosis)

 Diabetes

 Arterial thrombosis ⁄ macrothromboembolism and microthromboembolism (fibrin, platelets)

 Fat embolism (hypercholesterolemia, hyperlipidemia)

 Detachment of cholesterol-containing plaques from aorta, aneurysm, or atrium (atrial fibrillation)

 Thromboangiitis obliterans (Buerger disease)

 Arteriovenous anastomosis (congenital ⁄ traumatic)

 Trauma, rupture, infection, vascular procedures

 Fibromuscular dysplasia

Microcirculatory disorders

 Raynaud phenomenon, scleroderma

 Hypertension: ulcus hypertensivum (Martorell ulcer)

 Increased blood viscosity (increased fibrinogen level, paraneoplastic, paraproteinemia, leukemia)

 Blood transfusion reactions

Vasculitis

 Small vessel: small vessel-leukocytoclastic vasculitis, microscopic polyangiitis, Wegener granulomatosis, allergic granulomatosis (Churg–Strauss), Henoch–Schonlein purpura, essential cryoglobulinemic vasculitis, erythema induratum Bazin, livedo reticularis, livedo vasculitis, and Sneddon syndrome

 Medium-sized: polyarteritis nodosa, Kawasaki disease

 Large vessel: giant cell arteritis (polymyalgia rheumatica, Takayasu arteritis)

Hematological disorders

 Sickle cell anemia, other forms of anemia, thalassemia, hereditary spherocytosis, glucose-6-phosphate dehydrogenase deficiency, essential thrombocythemia, thrombotic thrombocytopenic purpura, granulocytopenia, polycythemia, leukemia, monoclonal dysproteinemia (Waldenstrom disease, myeloma), polyclonal dysproteinemia (cryofibrinogenemia, purpura, hyperglobulinemia, cold agglutinins)



Arterial ulceration almost always involves bony high point and is due to pressure necrosis where the relatively mild pressures involved are sufficient to cause ischemia where the arterial perfusion pressure is low.

Arterial ulcers are associated with pain making them very distinct from venous ulcers. Vascular pain is a complex issue leading to sympathetic changes causing skin hyperalgesia, dystrophic skin with shinny appearance.

According to a recent report, chronic kidney disease (CKD), hypertension, and myocardial ischemia may also be associated with increased risk of developing foot ulcers including severe ulcers that necessitate amputation [8].



11.4 Clinical Features



11.4.1 History and Assessment


The first step toward diagnosis of any leg ulcer is to compile a comprehensive history and assessment of the patient (Table 11.2) [9]. This should include general health status, social and occupational situation, past and current medical history of relevant diseases (such as deep vein thrombosis, diabetes, autoimmune disorders, inflammatory bowel disease, and connective tissue disease), condition of the skin, current vascular status, limb size and shape, and history and status of the ulcer.


Table 11.2
Characteristics of different types of ulcers












































































Cause

Site/no

Size/shape

Floor/base

Edge

Surrounding skin

Pain

Associated Vasc Sx

Arterial

Malleoli

Foot (dorsum)

Ant. shin

Small, punched out

Deep

Poorly developed

Necrotic

Minimal granulation

Little bleed

Flat

± gangrenous

Lack inflammation

Pale mottled

±gangrene

Yes

Significant

Rest pain

Claudication

P.Hx ulcers or surgery or angioplasty or tissue loss

Venous

Gaiter

Often large and messy

Shallow

Granulating

Sloping

Lipodermatosclerosis

±2° lymphedema

± atrophie blanche

Yes

No arterial Sx unless combined.

Previous Ulcers/DVT/compression Rx etc.

Neuropathic

Pressure areas – foot (great and little toe), May be Charcot’s foot

Deep

Often based on joint/tendon/bone

Indolent

Indolent

Look for deformity of the foot

±Callus

Acute on chronic inflammation

No

No vascular Sx unless superimposed PVD

Infective

Atypical position

Variable

±Granulation, slough

Variable

Variable

Cellulitis

May be normal

Variable

Well-perfused skin, no chronic changed unless chronic infection

Trauma

Atypical

Ragged in some cases

Bleeding, Should granulate

Trauma dependent

Often normal

Yes

Hx trauma

Vasculitis

Often multiple

Small

Inflamed, indurated base

Variable

± rash/inflammation.

Background of palpable purpuric change

Yes

Look for skin/joint/CREST/genital/serosal/constitutional manifestations/deep organ manifestations

The patient should be asked about lower extremity pain, paresthesia, anesthesia, and claudication. It is important to determine the duration of ulceration and whether it is a first episode or recurrent. Pain is a major problem for patients with leg ulcers unless there is a neuropathic component. Lack of pain, therefore, suggests a neuropathic etiology. Patients should also be asked about their mobility.

A typical arterial ulcer is located distally in extremities (toes, heels, and bony prominences of the foot) and usually present with nocturnal rest pain. The ulcer appears “punched out,” with well-demarcated edges and a pale, nongranulating, often necrotic base (Fig. 11.1a), which differentiates it from other types of ulcers (Table 11.3). The surrounding skin may exhibit dusky erythema and may be cool to touch, hairless, thin, and brittle, with a shiny texture. The toe nails thicken and become opaque and may be lost [10]. Gangrene of the extremities may also occur.

A327068_1_En_11_Fig1_HTML.jpg


Fig. 11.1
(a) Arterial ulcer, (b) vasculitic ulcers, (c) Martorell ulcer



Table 11.3
History and assessment of the patient with limb ulcer































































Patient

 History of ulcer development

 Past and current medical problems

 General health status

 Nutrition

 Social, occupation

 Mobility problem

 Limitations to self-care

 Obesity

Skin changes

 Arterial

 Malignant

 Autoimmune

Vascular assessment

 Pedal pulses

 Ankle–brachial pressure index

Limb factors

 Edema

 Circumferences

 Lymphedema

 Orthopedic problems

 Sensation and pain

Ulcer

 Site-venous, arterial, pressure

 Appearance

 Size measure

 Wound base

 Exudate level

 Surrounding skin

Vasculitic ulcers tend to have some characteristics similar to ischemic ulcers, including their location, size, and shallow depth. There are several typical differences, however. Vasculitic ulcers frequently have irregular shapes and borders (Fig. 11.1b). Additionally, the floor of the wound tends to be necrotic with significant vascularity. The surrounding skin is usually hyperemic rather than pale. Vasculitis may also feature other cutaneous manifestations, including palpable purpura, petechiae, and persistent urticaria [1].

A rare condition exists called Martorell ulcer (Fig. 11.1c), seen in patients with prolonged, severe, or suboptimally controlled hypertension [11]. The ulceration is secondary to tissue ischemia caused by increased vascular resistance. The ulcers are usually located at the lower limb, above the ankle region, contain black necrosis and are extremely painful. By definition, the distal arterial pulsations are normal, and the diagnosis is made by histological examination, which shows concentric intima thickening and marked hypertrophy of the media of small-sized and medium-sized arteries, and by exclusion of other conditions that may cause ulceration in this area. The differential diagnosis consists of arteriosclerotic occlusion of small-sized arteries, diabetic angiopathy, vasculitis, thromboembolic occlusion (e.g., in atrial fibrillation), and pyoderma gangrenosum. Treatment consists of reducing hypertension, adequate control of pain, and local wound care [12].

Examination of the arterial system may show a decreased or absent pulse in the dorsalis pedis and posterior tibial arteries. There may be bruits in the proximal leg arteries, indicating the presence of atherosclerosis.

Clinical course of the ulcer can suggest its etiology. Possible considerations to rule out include diabetes; hypertension; hyperlipidemia; coronary artery disease; alcohol and tobacco use; thyroid, pulmonary, renal, neurologic, and rheumatic diseases; and specifically cutaneous factors including cellulitis, trauma, and recent surgery.


11.5 Diagnosis


Diagnosis includes blood investigations for risk factor screening and noninvasive and invasive vascular investigations.


11.6 Blood Investigations


Blood investigations such as complete blood count, erythrocyte sedimentation rate, blood sugar, lipid profile, renal function tests, and liver function tests are essential in patients with chronic leg ulcers.

Laboratory screening tests for vasculitis: urine analysis for proteinuria, hematuria, cylindruria, routine and immunohistopathology of skin biopsies, antinuclear antibodies, rheumatoid factor, complement C4, circulating immune complexes, paraproteins, immunoglobulin fractions, antineutrophil cytoplasmic antibodies (ANCA), serological tests, and cultures for underlying infections [13].

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May 13, 2017 | Posted by in GENERAL SURGERY | Comments Off on Arterial Ulcer
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