Arterial

and
Venous
Ulcers
Arterial and Venous Ulcers
 Arterial Ulcer Epidemiology
Leg ulcers occur in approximately 1% of the
population at some point in their lives
About 25% of these ulcers are arterial origin
Associated with claudication, rest pain, gangrene
and localized ulceration
Located almost exclusively in the distal lower
extremity
Ischemia is common especially with smokers,
Diabetes and in elderly
 Leg ulcers
Concern of the cost

Pain & suffering

Body image change

Struggle for control, independence

Depression, isolation

Social Issues
 Arterial & Venous Ulcer Goals

Understand the pathogenesis (underlying

medical problems)

Accurate assessment – differentiate between

venous, arterial, mixed etiologies

Identify and manage risk factors to facilitate

prevention and early intervention

Management of ulceration – underlying

etiology(cause) & wound
 Arterial Ulcers
Result of Reduced Blood Supply due to:
Atherosclerosis
(accumulation of plaque)
Emboli
- narrows lumen of artery
- leads to infarction &ischemia
- diminished arterial blood supply
- decreased delivery of O2 & nutrients
- leads to tissue hypoxia and necrosis
 Arterial Ischemia Assessment

History of:
Cold feet
Intermittent claudication - pain in
leg/buttock with walking
Rest pain - in toes & forefoot
Pain aggravated by elevation &
relieved by dependency
Smoking, diabetes, hypertension,
Hyperlipidemia, CAD, age
Arterial Insufficiency Ischemia
 Inspection: Vascular
Colour – pale
Assessment
Dependent rubor- with -
Elevation pallor
Decreased capillary refill time
(>15 sec.)
Atrophy of subcutaneous fatty
tissue
Shiny, thin, tightly drawn skin
Loss of hair on foot and toes
Thick, yellow, brittle nails
Vascular Assessment
Dorsalis pedis

Palpation:
❈ Cool to touch
❈ Absence of pedal Posterior tibial
pulses
❈Blanch test
 PAD – Peripheral Vascular
Disease
Non-healing foot ulcers

Due to impaired delivery of:

Oxygen
Nutrients
Antibiotics
 Ankle Brachial Index (ABI)
Monitors systolic pressure of ankle and
brachial arteries with use of a doppler
monitor
Ankle figure divided by brachial figure for
index number
Diabetics may have arteriosclerosis and toe
pressures are required as regular ABI's
may be lower then indicate
Transcutaneous oxygen levels (TpO2) have
proven to determine adequate circulation
equal to or better then Toe pressures
 ABI ABI = 0.8
Blood flow in ankle
Ideally the ABI should be 1.0 is 80% of that in
Arterial the arm
ABI Insufficiency

1.0 - 1.2 none

0.8-1.0 mild
0.6 - 0.8 moderate
Below - 0.6 severe

ABI of ≤ 0.5 Vascular Consult

re-establishment of an a
adequate vascular supply is indicated if feasible
 Vascular Assessment
Vascular Lab:
Toe pressures more accurate
<25 mmHg represent severe occlusion
>30 mmHg needed for healing to
occur
>45 mmHg in people with diabetes
Arteriography (diagnosis of by-passable
conditions- surgery)
Transcutaneous oxygen pressures ->30%
 Arterial Ulcer Characteristics
Trauma – most common
precipitating event

Usually very painful

Circular or punched out

appearance

Painful if leg elevated

 Arterial Ulcer Characteristics

Usually on distal areas of foot-toe tip,

between digits, over bony prominences or
other areas d/t trauma
 Arterial Ulcer Characteristics

Wound bed - necrotic tissue (black or yellow) or

pale greyish/pink granulation base
Little exudate, dry and necrotic
Surrounding tissue pale or mottled
 Determine Potential for Healing
Assess Patient and Wound for:
Blood Supply

Important for wounds of lower extremities

If inadequate:
- moist interactive wound healing is
contraindicated
use topical antiseptics
vascular referral to determine if
re-vasculization possible
Management of Arterial Ulcers
Patient History
Treat the cause
medical consult
surgical consult (vascular)
surgery: restoration of adequate blood
supply
Arterial by-pass ( autogenous vein or
prosthetic graft)
Angioplasty
 Interventions to Maximize
Blood Flow – Treat the Cause
Smoking cessation (causes vasoconstriction)

Warm environment(socks, avoid drafts)

Exercise (as tolerated)

Pain Management (pain causes

vasoconstriction)

Elevation of leg contraindicated

Legs at rest should be in neutral position

 Management of Arterial Ulcers
Avoid treatments that interfere with arterial
flow:
whirlpool
sharps debridement
compression therapy
restrictive footwear
elevation of limb above heart level
Management of Co-morbid diseases(diabetes)
Optimal nutrition
Management of Arterial Ulcers
Maintain walking with rest periods when
pain occurs
Treat for pain around the clock
Manage exudate and odour
Position bed so feet lower then heart
Treat infection – continual assessment for
signs of infection – change in pain
-change in exudate appearance
-change in odour
- change in client behaviour
withdrawn, decreased appetite,
restlessness
Management of Client Concerns
Communicate Fears – provide support
Family/Client education
Independence with wound care when possible
Maintain self esteem through activity and self
care
Understanding in regards to pain
Maintain Mobility
Alternative Therapies -relaxation
 Treat the Wound Goal
– Prevent/treat Infections and
Avoid/Delay Amputation
Moist healing only if adequate blood supply
to heal
Keep area clean & dry if not adequate blood
supply to heal
Avoid debridement
Use Povidone iodine to paint wound
If wound wet consider a topical antimicrobial
Assess & treat for infection if needed
 Arterial disease
Signs of adequate blood supply?

a) Feet warm to touch, pulses present

b) ABI < 0.6
c) Colour bluish hue
d) Hairless legs (culture sensitive)
e) all of the above
Arterial Ulcers are painful when legs
hang down?

True

False
Arterial ulcers characteristics consist of all
except

a) punched out in appearance

b) distal extremities
c) wound base deep red colour
d) pain with elevation
ABI and Toe Pressure
assessments determine the
amount of venous pressure.

True

False
 A B C D

Which photo shows a arterial

ulcer?
 Group Discussion
What have you seen in your practice?

What was the hardest element of treatment?

What was the most difficult element for the

patient?

What were the solutions implemented or

tried?
 Questions?

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Venous Leg

Ulcers
 Leg Ulcer Epidemiology
According to the Canadian Medical
advisory Secretariat (MAS),2006 as cited
by Burrows et al

prevalence of lower limb ulcers 0.12%-

0.32% in general population

approximately 50,000 to 500,000 Canadians

with leg ulcers
 Leg Ulcer Epidemiology
most people with venous leg ulcers
were over the age of 65 and nearly
75% had 3 or more medical
conditions (Harrison et al, 2005)
>2/3 had ulcers for many months, ½
affected population had leg ulcer
history that spanned 5 – 10 years
estimated cost of 192 people
receiving treatment costs $1
million in nursing care and
$260,000 in supplies annually
 Venous Leg Ulcers
1994 survey of people with venous ulcers

81 % adverse effect on mobility

56% spent up to 8 hours per week on ulcer

care

68% negative emotional impact, including

fear, social isolation, anger,depression,
negative self esteem

cost per patient $40,000 - $90,000

 Venous Hypertension - Etiology
Valve dysfunction (deep,perforators,superficial)
Obstruction from complete or partial blockage of
the veins( DVT)
Failure of calf muscle pump function ( decreased
activity)
Previous varicose vein surgery
Previous DVT
Congenital
Increased abdominal pressure (morbid obese,
pregnant)
 Venous Drainage
Deep venous system -
under muscle fascia
Superficial venous system
- close to skin (greater &
lesser saphenous system)
Perforator or
communicating veins -
join deep venous system
& superficial venous
system
 Venous Drainage
One way valve system
- prevents backward flow of blood

Calf muscle pump

- calf muscles contract
& squeeze venous blood
upward toward the heart
need to walk from heel to toe
or flexion and extension of ankle
beyond 45 degrees
Normal Incompetent
Valves Valves

Superficial

Perforator

Deep
 Venous Stasis Disease
Risk Factors
Family History

Obesity

Pregnancy

Occupations that require

long hours of standing or sitting

History of:
DVT,Leg injury, Varicose Veins or vein
stripping
 Venous Stasis Ulcer Disease
underlying etiologic factors

Sustained venous hypertension

due to
Valvular dysfunction

Obstruction

Calf muscle pump failure

causes
localized ischemia due to edema
 Clinical Features & Diagnosis
Dilated long Saphenous vein
Edema (weeping exudate) worse at the end
of the day
Stasis Dermatitis (itchy/dry)
Hemosiderin & Melanin deposition (brown
skin staining)
Lipodermatosclerosis (woody appearance)
Atrophic blanche (white scars)
Pain or ache (worse with dependency,
relieved by elevation, worse at end of the
day)
 Contributing Factors for
progression to ulceration

Trauma

Infection

Edema

Malnutrition

Immobility
 Assessment & Diagnosis

Complete history (medical and social)

Wound assessment

Vascular Assessment

Investigations
 History
Medical history – cardiac or pulmonary disease
including CABG
Assess history for:
swelling at the end of the day
varicose veins/ vein stripping, abdominal
surgeries, DVT
previous ulcers/treatments
lower leg trauma
prolonged standing
compression treatments
 Wound Characteristics

Rapid development
granulating wound
base
(may be necrotic initially)
red base in colour
Jagged/irregular wound edges – shallow
located above medial or lateral malleoloi
(gaiter area) or on anterior tibial area –
 Wound Characteristics
Edema
Exudate is usually copious & serous
Peri- wound skin may have dermatitis,
hyperemia, maceration, hyper
pigmentation, & thickening
Feet warm with palpable pulses
Pain or ache – relieved by elevation
May be complicated by bacterial infection
 Treat the Cause
Underlying Pathology
Timely identification of people at risk
Elevation - reduces Edema/venous pressure
Maximize mobility - consult rehabilitation experts

Calf Muscle Pump Exercises

ROM
Compression - the corner stone of treatment
Weight management
Skin care
 Compression

ABI > 0.8 – full compression

ABI 0.6-0.8 – lower (mild to moderate

compression) consult advanced wound
clinician
ABI, < or = 0.5 no compression – refer to
vascular surgeon

Jobst Sigvaris
 Compression

Contraindicated if arterial disease is present

Patients with diabetes may have
elevated ABI's due to calcified
arteries – toe pressure needed by
vascular lab or subcutaneous oxygen
Compression is not for use in acute
CHF,
DVT, or infection
 Underlying Pathology
Management

Compression therapy

Compression bandages

Intermittent pneumatic compression devices

Modified compression

Compression garments – once edema

controlled
Clarification of Compression
Bandages
Elastic

pressure characteristics example

Low single layer tensors

Moderate single or double Tubigrips

High Long Stretch ProGuide

High Four Layer Profore

 How To Measure Fit
STEP 1: Measure the circumference of your ankle.
Measure around the narrowest part of your ankle above
the ankle bone. Record this measurement...

STEP ONE
 Measure to Fit

STEP 2: Measure the circumference of your calf. Measure

around your calf at it's widest part. Record this
measurement...

STEP TWO
 Measure to Fit

STEP 3: Measure the length of your calf. Measure from the

floor to the bend in your knee. Record this measurement...

STEP THREE
 Measure to Fit
STEP 4: Measure the circumference of your thigh.
Measure around the widest part of your thigh just below
your gluteal fold. Record this measurement...

STEP FOUR
 Measure to Fit
STEP 5: Measure the length of your thigh. Measure from
the gluteal fold to the floor. Record this measurement...

STEP FIVE

Jobst Stocking Measuring Scale

STEP 6: Measure around your hips.
Locate the widest part of your hips
or waist and measure all the way
around
 Four-layer bandage for
sustained graduated compression
1 2

S S Profore Lite
Layers 1,2,4
natural padding bandage light conformable bandage

•Apply all
3 4
elastic layers
at half-stretch
8 S •Change q 7
days
S = spiral
8 = figure 8
light compression bandage flexible cohesive bandage
 T.E.Ds
T.E.D. Anti-embolism stockings are
not the same as support stockings
or compression hose. Yes, TED
Stockings do have graduated
compression to speed blood flow.
TED stockings are for the non-
ambulatory convalescing person to
prevent blood clots.
“T.E.Ds are for bed” compression hosiery is for
life
Samson & Showalter,1996
Graduated Compression Therapy
Reduces venous hypertension

Improves calf muscle pump

Increases venous return to the heart

Increases removal of Fibrin

Decreases edema

Decreases distension of superficial veins

 Classification of Compression
Bandages systems (inelastic)
Pressure Characteristic Example
Low flexible cohesive RoloFlex or
Padding Coban & cast
padding

Moderate Zinc Oxide bandage Duke Boot

& cohesive
Velcro system Circaid

Moderate short stretch system Comprilan

to High
 Compression Stockings
Prevention & Aftercare
 4 % recurrence in people who wore good
compression stockings.
79% recurrence in people who did not wear
good compression stockings.
 Any level of compression better then no
compression
 Teaching is the corner stone of adherence
 May need tools to assist in applying stockings

Compression hosiery for life

(Samson & Showalter, 1996)
 Compression Stockings
Dress support hose – 8.5 mmHg –
prominent veins without edema
Class I-20-30 mmHg – treat varicose veins
or mild edema
Class II – 30-40 mmHg – recommended to
treat more severe varicosities or moderate
edema
Class IV - >60 mmHg – for severe venous
insufficiency

Level of compression depends

on severity of venous hypertension
 Compression Stockings
Devices to assist with application
rubber gloves
nylon or silk sock
zipper inserts in the back

Action
compress dilated superficial veins
Use
remove stockings & bath at bedtime – moisturise
legs -re apply early in AM
2 pairs of stockings should be purchased
may need replacement every 6 months
 Summary
Some compression is superior to no
compression
high compression is superior to low
compression in the absence of significant
arterial disease
no clear difference in the effectiveness of the
different types of compression stockings

Fletcher et al. 1997

 Summar
y
Increased use of correctly applied
compression system should be
promoted

Elastic systems have an advantage

over inelastic systems

Fletcher et al. 1997

 Patient Education

Reduce weight if necessary

Avoid prolonged standing or sitting
walk/calf muscle pump exercises
Elevate feet above level of heart frequently
during the day

Periodic reminders of treatment plan for

prevention
 Patient Education
Optimum treatment of all co-morbid
conditions

Avoid tight bands of clothing around legs

Good skin care – use of emollients

Venous ulcer reoccurance = 72%

Wear compression for life

 Treat the Wound
Irrigate – 30 ml syringe with cathlon 18
gauge
Support debridement – autolytic/surgical
pain management
Rule out or treat infection
Apply dressing that supports moist wound
environment
Absorb excess exudate
 Appropriate Dressings
Foams
Calcium alginate
Hydrocolliods
Hydrogels
Transparent adhesive dressing
Zinc oxide bandages are an alternate
primary layer for use over the dressing
alone or under compression bandage
 If Conservative Therapy
Unsuccessful.....
Surgery Intervention
Grafting
Pinch grafting
Split thickness (disadvantage – donor site
painful & difficult to heal)
Biological skin substitutes
Ligation and Stripping
Arterial surgery for mixed & arterial
disease
Biopsy to rule out more unusual causes of
ulceration
<10% of venous ulceration are refractory
to medical management
Peripheral Vascular Disease
(Ischemia)
Impairs viability of skin
Inhibits/prevents wound healing
 ISCHE MIC F OOT UL CER

This pati ent has p reviousl y had mo st of th e

to es o f th is foo t re move d b ecause o f
gan gr ene but has fai led to h eal on e of t he
amp utati on si te s due to p ersi ste nt
isc hemia which or igi nat ed i n th e calf
 Mixed
Venous & Arterial
Coexisting illnesses

Optimal
Management

Venous Arterial
Reflux Insufficiency
 Differential Diagnosis
Venous & arterial insufficiency coexist in
about 20% of patients
Prior to the application of compression, an
arterial assessment must be done (ABI,Toe
Pressures,Transcutaneous Oxygen)
If compression is applied to a limb with
impaired arterial blood supply serious
damage can result
 Mixed Arterial/Venous Ulcer
Management
Address limb threatening disease –
maximize flow (surgical consult)
Pain control
Passive control of leg edema
position limb at heart level
modified compression – Tubigrips
Prevent infection
topical antiseptics
 Compression Therapy

Level Etiology Compression

0.8 – 0.9 Venous High
0.5-0.8 Mixed Modified (low)
Less then Arterial None
Guidelines for interpretation of ABI &
compression therapy
 Arterial & Venous Ulcer
Treat the cause
arterial
venous
mixed
Treat the Wound
moist wound healing (if adequate blood
supply to heal)
Treat the patient
pain, compliance, adherence to treatments,
nutrition, Life style changes, & follow up
Type of vascular disease needs to be
known prior to compression?

True
False
Mixed disease means:

a) venous & arterial flow diminished

b) client has multiple co-morbid illness
plus a ulcer
c) a ulcer on the plantar foot surface is
present with Hemosiderin staining
d) no pain with elevation or hanging of
feet
Hemosiderin staining is:
a) a large bruise to lower legs from DVT
b) dull woody appearance on lower leg
caused by edema
c) white spot on the skin that does not
blanche
d) brown staining to lower leg associated
with venous disease
Compression is a treatment option for
mixed disease
a) all the time
b) according to ABI
c) only if palpable edema present
d) never
78 year old male
recent widow, no
children
mixed farming
early spring
quit smoking 1 year
ago
Diagnosis and why
hauls water – no well
Potential cause
Treatment recommendation
If lower leg is red but fades with
elevation what could this indicate?

a) arterial disease
b) phlebitis
c) Cellulitis
d) vascular disease
 Questions?

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