Section: Vascular Curriculum: Curriculum, page 54

Definition

Area of epidermal loss that has not healed within 6 weeks
- Ulcer = Persistent discontinuity of the epithelial surface

Incidence

Lymphovascular (90%)
- Venous (50-70%)
- Mixed venous & arterial (10-20%)
- Arterial (10%)
- Lymphoedema
- DM → Microvascular disease (& secondary neuropathy)
Blood dyscrasias
- Thalassemia, Sickle Cell disease, Polycythaemia Rubra Vera
Inflammatory
- Vasculitis – RA/ SLE/ Polyarteritis Nodosa
- Pyoderma gangrenosum (RA/ UC)
- Infective: e.g. TB
- Underlying Osteomyelitis
Neoplastic
- Malignancy – e.g. Squamous cell carcinoma, Basal cell carcinoma, Melanoma
- Marjolin ulcer
Trauma
- Obesity / Pressure sores – reduced mobility – won’t use calf muscle pump as much
- Neuropathic ulcers = 2° to an inadequate sensory nervous system
  - E.g. DM, nerve injuries, leprosy, spinal cord lesions

History
- Pain (Lack of = neuropathic)
- Systemic diseases
- Hx of trauma
- Hx of DVT/ varicose vein treatment
- Mobility
- Examine arterial system, nervous system & veins
- Distribution of trophic & ischaemic ulcers may be similar (as the pressure points are same in both – e.g. over heel; distribution dependent on whether pt is bed-bound or ambulant)
Arterial ulcers
- Painful, punched out, often on pressure areas
- Ischemic ulceration
  - Large vessel disease; atherosclerosis or embolism
  - Small vessel disease: DM, Buerger’s disease, microembolism, pressure necrosis / trauma, Scleroderma, Raynaud’s
Venous ulcers
- 90% - medial aspect of lower third of the leg, above medial malleolus = Gaiter area
- May not be very painful, especially if chronic
- Granulation tissue in base, uneven epithelial margins (peripheral healing)
- Shallow with sloping edge
- Raised/thickened edge in a chronic venous ulcer should raise the suspicion of malignant change (Marjolin ulcer)
- Frequently colonized with bacteria, but may not be infected
- Infection more likely if bacterial load is > 105 organisms/ gram of tissue or if β-haemolytic strep is present at level of 102 organisms/ gram

Repeated pressure & trauma contribute the cause of both ischaemic & trophic ulcers
Microbiology
- S. aureus (≈ 40%)
- Pseudomonas Aeruginosa (≈ 25-30%)
Of the pts with venous ulceration
- 50% have reflux in the superficial system alone
- 38% have reflux in both superficial and deep venous system
- 10% reflux in the deep system alone

ABI/arterial studies
Test for glucose
Vasculitis screen: ESR, CRP, ANA, RhF, ANCAs
Consider punch Bx to rule out malignant ulcer / malignant change
Culture – Strep Group A, Staph aureus – colonisation common, routine bacterial cultivation not necessary
Imaging
- Arterial system and venous system as indicated

Consider all causes of leg ulcer (arterial disease, vasculitis, DM)
- Stop smoking
Chronic venous ulceration
- Graduated compression stockings – Class 2 usually effective
Elevation
Exercise
Dressings
- Wounds heal 50% faster when moist
- Occlusive dressing – Hydrocolloid (Duoderm, Comfeel)
  - Change every 5-7 days
  - Forms gelatinous barrier
  - Lower infection rate, equivalent healing time, less pain
  - Non-adherent - reforming epithelium does not get damaged when removed
Debridement of necrotic tissue (prevents epithelialization & encourages infection)
Infection treatment
- if appropriate - no evidence for routine ABs
Manuka-honey
- Non-sig improvement
- Cochrane 2008: no benefit, except in burns?
DVT prophylaxis
Diuretics
Aspirin – evidence inconclusive
Diabetic ulcers
- Hyperbaric oxygen ↓s amputation rates but is expensive
For mixed ulcers
- If ABI > 0.8: Compression bandaging
- If ABI 0.5 - 0.8: Modified compression ± consider for revascularization if ulcer not healing
- If ABI < 0.5 → Refer for vascular revascularization surgery (before debriding)

Improves ulcer healing and lowers rates of recurrence
Goals
- Definitively treat any refluxing axial veins, associated pathologic perforator veins, or associated varicose veins.
Types
- Superficial axial venous ablation
  - See Varicose veins
    - Endovascular vs Surgical
- Pathologic perforating veins
  - Mostly teated endovascular now but can use open ligation and subfascial endoscopic perforator ligation
- Deep venous obstruction or insufficiency
  - Iliocaval venous obstruction
  - Femoral or infrainguinal obstruction

Venous
- Ulceration: Healing rates 70-80% at 24wks, ≈ 20% resistant
- 12-month ulcer recurrence rates 30% (though may be up to 70%)
- Recurrence rates ↓ in pts who have compression + surgery for their veins: At 3 yrs: recurrence rates = 10 vs 40% In those treated with compression alone
Risk factors for poor healing
- Age
- Ulcer chronicity (> 3 months)
- Venous refill time ≤ 20s with a below knee tourniquet
- Smoking
- Ulcer size

Chemical debridement