Treatment

Arterial ulcers are notoriously difficult to heal and prove challenging to the practitioner. Arterial surgery to improve the blood supply may be necessary before an arterial ulcer will heal (Vuolo, 2009). In severe ischaemia, healing may not be possible, and the goal becomes prevention of infection and the delay of potential amputation.

Management is complex and is best accomplished by an interdisciplinary team approach (Wounds UK, 2019). Infection can cause rapid deterioration in an arterial ulcer, and treatment with systemic antibiotics should be started (Grey et al., 2006).

Surgical Intervention & Drug Therapy

Increasing the peripheral blood flow by, for example, reconstructive surgery (for diffuse disease) or angioplasty (for localised stenosis) is the intervention most likely to affect the healing process in arterial ulceration (Grey et al., 2006).

Angioplasty and Stents

The simplest of treatments for removal of an occlusion which is causing arterial ulcers is balloon angioplasty. The catheter is placed in the artery and fed to the area of the blockage. The balloon is then inflated to squeeze the blockage against the vessel wall and open the vessel up. Stents are small metal structures that can be inserted into the artery after angioplasty to hold the artery open (Vuolo, 2009).

Arterial Bypass Surgery

When the atherosclerosis is severe enough to interfere with daily activities, bypass may be recommended. Bypass surgery is performed to restore circulation to ischaemic extremities. Surgery involves the creation of a detour past the areas where the vessels are blocked (Vuolo, 2009).

Drug Therapy

Leg ulcers are frequently painful, particularly if they have an arterial component or are associated with cellulitis or deep infection, and strong analgesics are likely to be required (NICE, 2015). Drugs used for improving leg pain and function are generally those that either prevent blood clots (typically antiplatelet drugs) or improve blood flow.

Wound Management

The main treatment aim would be to keep the arterial ulcer dry and protected from pressure. Maceration of the wound and surrounding skin must be avoided as it will increase the extent of tissue loss and promote bacterial proliferation. Often, gangrenous lesions of the toes are left to dry out so they will autoamputate (Vuolo, 2009). The selection of a dressing should be chosen following a wound assessment and responding to any changes in the clinical appearance in the wound.

Mixed Aetiology Ulcers

Ulceration of mixed aetiology is not uncommon. Patients may have a combination of venous and arterial diseases, which will limit the degree of compression (if any) that can be used (Grey et al., 2006). It is important to define the predominant factor, so that appropriate treatment may be given. These patients may need a duplex scan to determine the predominant cause of their ulcer (Vuolo, 2009).

Treatment

Treatment will depend on the individual patient and whether the predominant factor is arterial or venous. If the main factor is venous, moderated graduated compression may be appropriate. The degree of compression should be based on the patient’s tolerance of the compression and the degree of arterial involvement. If compression therapy is used in these patients, great caution must be exercised, and the patient must be monitored closely.

If arterial disease predominates, a vascular surgeon’s opinion should be obtained. Exercise and periods of limb elevation can be encouraged, within the tolerance of the patient (SIGN, 2010).

Further information regarding diabetic ulcers can be found in Section 7 of this module (Diabetic Foot Ulcers).

This section has given guidance regarding leg ulcers concentrating on how they should be assessed and managed. Practitioners must ensure that they are acting within local and national guidelines as well as their own competence when managing patients with leg ulcers.