Arterial and Venous Ulcers

Presented by Amelia E. Quiz

Emory University

Objectives

Define arterial and venous ulcer through: Disease etiology Patient’s history Clinical presentation

Discuss assessment and diagnostic components.

Determine management or treatment strategies.

ARTERIAL ULCERS Ulcers resulting from

peripheral arterial disease (PAD).

VENOUS ULCERS Ulcers resulting

from venous insufficiency or venous HTN.

DISEASE EPIDEMIOLOGY:ARTERIAL ULCERS

Increases with age Greater among men

(CDC, 2002)

DISEASE EPIDEMIOLOGY: VENOUS ULCERS

Incidence and prevalence have not been well established (5).

The prevalence of venous ulcer varies greatly (4).

Unhealed venous ulcer is approximately 0.3%,

i.e. about 1 in 350 adults (2).

70% of chronic ulcers of the lower limbs (2).

Greater among women (2). Increases with age (65 & older) (5).

Impact on the Quality of Life

Affects lifestyle Inability to work Social isolation Frequent hospitalizations or clinic

visits Feelings of anger and resentment

DISEASE ETIOLOGY: Risk factors

ARTERIAL ULCERS Atherosclerosis Hx of MI or CVA Hyperlipidemia DM Tobacco use Hypertension Hyper-

homocystinemia

VENOUS ULCERS DVT Obesity Multiple

pregnancies Limited ROM ankle

joint Sedentary lifestyle Thrombophilia

Pt’s. history, Focused PE, Symptoms and Complaints

Ulcer History Onset Duration Prior treatment Response to

treatment

Pain History Severity Description Exacerbating

factors Relieving factors Location

Clinical Presentation of Arterial Ulcers

Location –distal aspect of extremity, pressure points of the foot, area of trauma

Wound size & shape – small craters; well-defined borders (punched out)

Wound bed – pale or necrotic

Exudate – minimal or dry, no edema

Surrounding skin – faint halo of erythema or slight fluctuance. Gangrene, necrosis or infection is common

Increased pain & tenderness

Clinical Presentation of Arterial Ulcers (cont’d)

Clinical Presentation of Venous Ulcers

Location – gaiter area, particularly medial malleolus

Wound edges and depth – irregular edges and shallow

Wound bed – ruddy red; yellow adherent or loose slough; undermining or tunnels uncommon

Exudate – large Surrounding skin –

macerated, crusted, scaling, hemosiderosis, edema, dermatitis

Pain – variable (dull, aching or bursting)

Clinical Presentation of Venous Ulcers (cont’d)

ASSESSMENT AND DIAGNOSTICS

PHYSICAL EXAM Vascular Assessment Sensorimotor Assessment Ulcer Assessment

Vascular Assessment Color/response to

elevation and dependency

Temp./warmth Status of

skin/hair/nails

Vascular Assessment (cont’d) Pulses – venous

and capillary refill Edema

Vascular Assessment (cont’d)

ABI

Sensorimotor Assessment Response to

5.07 monofilament

Vibratory response

Position sense

Sensorimotor Assessment (cont’d)

Toe/Foot deformities Gait/Wear patterns of footwear

Ulcer Assessment

Location Dimensions &

depth Appearance/color

or wound bed Status of wound

edges Volume of exudate Status of

surrounding tissue

DIAGNOSTICS LAB WORK-UP CBC ESR FBS Serum Albumin &

transferrin levels

DIAGNOSTICS (cont’d)

Arterial Ulcers Arterial duplex

ultrasound

DIAGNOSTICS (cont’d) Arterial Ulcers Plethysmography Transcutaneous

pressure of oxygen (TcPO2)

DIAGNOSTICS (cont’d)

Venous Ulcers Color duplex

ultrasound scanning

Guidelines for Management

(Etiology, Systemic Factors & Topical Treatment)

ARTERIAL ULCERS Surgical options Hyperbaric O2 Tx Pharmacologic Tx

Guidelines for Management

(Etiology, Systemic Factors & Topical Treatment) cont’d

ARTERIAL ULCERS Behavioral

strategies

Guidelines for Management

(Etiology, Systemic Factors & Topical Treatment) cont’d

ARTERIAL ULCERS Topical Therapy

Guidelines for Management

(Etiology, Systemic Factors & Topical Treatment)VENOUS ULCERS Surgical options Limb elevation Pharmacologic

Therapy

Guidelines for Management

(Etiology, Systemic Factors & Topical Treatment) cont’d

VENOUS ULCERS Compression

Therapy

Guidelines for Management

(Etiology, Systemic Factors & Topical Treatment) cont’d

VENOUS ULCERS Topical Therapy

Guidelines for Management(Etiology, Systemic Factors & Topical Treatment) cont’d

VENOUS ULCERS Bioengineered

Tissue

Case studies 65 y/o obese female,

retired nurse H/O multiple

pregnancies, DVT CC –Swelling and

aching pain on bil. Lower ext., pain is worse toward the end of the day. Relieved by elevation.

PE – Lower ext. - Edema, erythema, scaling, hemosiderosis

Diagnostics Treatment plan

Case studies 58 y/o male, auto

mechanic H/O smoking, DM2,

HTN, FH of MI & CVA CC – Before, “pain” on

the lower extremities while walking that is relieved by rest; now pain is present even at rest.

PE – Lower Ext - barely palpable pulse, pain, pallor, poikilothermia (cold), necrosis

Diagnostics Treatment

References (1)Bryant, R. (2000). Acute and chronic wounds. Nursing

management. (2nd ed.) St. Louis, MO: Mosby. (2) CDC Data & Trends (2005). Retrieved April 5, 2007 from

http://www.cdc.gov/diabetes/statistics/hosplea/fig4.htm (3) Fernandes Abbade, Luciana P., & Lastória, Sidnei (2005).

Venous ulcer: epidemiology, physiopathology, diagnosis and treatment International Journal of Dermatology. 44 , 449 –456

(4) Fowkers FGR, Evans CJ, Lee AJ. Prevalence and risk factors of chronic venous insufficiency. Angiology 2001; 52 : S5–S6.

(5) Margolis, DJ., Bilker, W., Santanna, J., Baumgarten, M. (2002). Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol. Mar;46(3):381-6.

Donnelly, Richard, Hinwood, David & London, Nick J M (2000). ABC of arterial and venous disease: Non-invasive methods of

arterial and venous assessment. StudentBMJ. August 08:259-302.

That’s all folks!!!