arterial ulcers by joel arudchelvam
TRANSCRIPT
Dr Joel ArudchelvamConsultant Vascular and Transplant Surgeon
Ulcer /Wound / Abrasion
A full thickness breach in the continuity of the skin
Partial thickness (epidermis) - Abrasion
Skin Anatomy
Wound healing
4 stages Haematoma formation Inflammation/ debridment Proliferation Remodelling / maturation
Inflammatory Stage Within 24 hours neutrophils, and macrophages migrate to wound
Characterized by redness, heat, pain and swelling
remove organisms ,dead tissue, secrete cytokines and growth factors for proliferative stage
approximately 4 to 5 days
Proliferative PhaseGranulation • Fibroblasts - collagen , proteoglycans• New capillaries
Growth factors – secreted by macrophages – •PDGF, TGF , VEGF
Epithelialization • Crosses moist surface
Remodelling
Reorganization of collagen (type III to
type I)
MMPs and TIMPs
Increase in tensile strength
Non healing ulcer / chronic ulcers
Ulcers not showing signs of healing by 6 weeks are called chronic ulcers.
In non healing ulcers…
Prolonged pro-inflammatory phase Persistent elevation of pro inflammatory
cytokines - Inhibits action of fibroblasts and epithelial cells
High MMPs, reduced TIMPs
Reduced VEGF – esp in CLI
Causes for non-healing ulcers.
1. Local causes-Repeated trauma-Presence of foreign body / slough-ongoing infection / osteomyelitis
2. Regional causes
-Venous-Arterial insufficiency-Neuropathic
3. Systemic causes -Diseases - diabetes mellitus, renal failure, etc.- Drugs - immunosuppressives, cytotoxic-Nutritional deficiencies - protein, Hb, vitamin and mineral
Causes for non-healing ulcers.
1. Local causes-Repeated trauma-Presence of foreign body / slough-ongoing infection / osteomyelitis
2. Regional causes-Venous
-Arterial insufficiency-Neuropathic
3. Systemic causes -Diseases - diabetes mellitus, renal failure, etc.- Drugs - immunosuppressives, cytotoxic-Nutritional deficiencies - protein, Hb, vitamin and mineral
Occlusive Arterial Disease - OADCauses
Atheromatous Risk Factors
Smoking Diabetes Hypertension Hyperlipidemia Advanced age
Inflammatory Buergers Takayasu Vasculitis
Presentation
• Claudication
• Rest pain
• Ulcer
• Gangrene
Fontaine classification
Stage Symptoms I Asymptomatic II Intermittent claudication
IIa Pain-free, claudication walking >100 m IIb Pain-free, claudication walking <100 m
III Rest pain IV ulcer / gangrene
Stage III and IV “critical limb ischaemia”
Ulcer
In distal part of limb (forefoot or toes)
Dry Painful
Features OAD
Atrophic thin leg Lack of hair Shiny skin Brittle nails Absent pulse Cold Associated
gangrene
Natural history of ischaemic ulcers
Ankle Brachial Pressure Index (ABPI) ABPI{Leg} = P{Leg} / P{Arm}
P leg - blood pressure of dorsalis pedis / posterior tibial arteries
P Arm - brachial systolic blood pressure
Less than 0.9 is abnormal ABPI < 0.5 is better predictor of non
healing
Imaging
USS + Doppler – duplex scan
CT/MR Angiography
Duplex scan USS + Doppler
Can visualise the vessels, stenosis, plaques
Can see the flow and its quality
Non invasive Good for infrainguinal
vessels Abdomial vessels –
obscured by bowel gas
Angiography CT angiography
Catheter angiography
CT Angiography
NORMAL
Conventional angiography / DSA
Treatment for chronic ulcers
Local
Regional
Systemic
Treatment for chronic ulcers Local Wound toilet
o Process of removal of slough, dead tissue, foreign bodies and draining pus.
o Following a wound toilet the wound base is made suitable for future granulation and epithelialisation.
o Ischaemic ulcer – if infected / wet – wound toilet before revascularization / otherwise (dry scab, dry gangrene ) revascularization and then wound toilet
Management
Indications for revascularisation
1. Disabling claudication
2. Rest pain
3. Tissue loss
(Fontaine stage IIB, III, IV)
Management
Surgical
1.Bypass2.Endarterctomy
Endovascular1.Angioplasty and/2.Stenting
Amputation
Angioplasty and/ Stenting
Bypass
Conduits / Grafts
1. Autogenous
Reversed Saphenous v ein Graft ( RSVG)2. Synthetic
PTFE
polyester(DACRON)
Treatment for chronic ulcers Systemic causes
Correct anaemia, vitamin deficiency and other nutritional deficiencies.
Optimization of underlying comorbidities.
Role of antibiotics in wound - indicated only in patients with evidence of local or systemic infection.
Wound dressings
The material which is applied to the surface of the wound to cover it is called a dressing. 1ry – dressing which touches the wound 2ry – dressing used to cover the primary
dressing
Ideal wound dressing
Characteristics Provide a protective cover Maintain moisture Absorb exudates Does not induce pain or itching Easy to remove / does not adhereAllows gaseous exchange Cheap Freely available
Types of Wound Dressings
Gauze dressings Tulle Hydrocolloid dressings Hydrogel dressings Alginate dressings Foam dressings Transparent film dressings Etc.
Gauze
Cheap Freely available
Dry Painful on removing Damages epithelium
Tulle
Cheap Freely available Does not adhere Does not damage
epithelium Easy removal
E.g : Vaseline
Hydrocolloid Dressings•Made up of pectin based material
•Come in various shapes and sizes
Hydrogel DressingsMade up of water in a polymer to maintain moistureused in dry wounds
Silver Dressings Slow release of silver ion Antimicrobial to reduce bio burden of
wound e.g. Acticoat, Biatin Ag, Atruman Ag
Vacuum assisted closure VAC
Vacuum assisted closure VAC
Vacuum assisted closure VAC Macrostrain - stretch that occurs when
negative pressure is applied.
Draws wound edges together Provides direct wound contact Removes exudate and infectious materials
Microstrain - micro deformation at the cellular level Reduces edema Promotes granulation tissue
by facilitating cell migration and proliferation
Vacuum assisted closure VAC Indications for use
Large wounds Cavities Large amount of exudate
When to change dressings
When there is an indication to change Soaking Pain Need to inspect
Discuss with doctor before changing
Avoid
• Do not tie gauze bandage tightly around limbs, digits – causes ischaemia
• Use – plaster , crepe instead
Avoid in chronic wounds
Iodine (Betadine) Hydrogen peroxide Other toxic agents
ARTERIAL ULCERS
Recognise OAD Refer appropriately
Assess fitness for intervention Correct the occlusion
Correct systemic factors / co morbidities
Keep wet Do not apply tight dressings
Thank You