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What are the distinguishing characteristics of an arteriole ulcer?
Ischemic ulcers occur in patients with diminished or absent pedal pulses, have discrete borders with a "punched out" appearance, are often painful, and can be associated with wet or dry gangrene. The base of the ulcer is usually fibrous, pale pink or dry black or brown eschar. Other clinical signs include: cold, pale, or cyanotic foot, absence of digital hair, and thin atrophic skin.
Carter SA, Tate RB.
Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia.
J Vasc Surg. 1996 Aug;24(2):258-65.
PMID: 8752037 [PubMed - indexed for MEDLINE]
Barnes RW, Thornhill B, Nix L, Rittgers SE, Turley G.
Prediction of amputation wound healing. Roles of Doppler ultrasound and digit photoplethysmography.
Arch Surg. 1981 Jan;116(1):80-3.
PMID: 7469736 [PubMed - indexed for MEDLINE]
Hafner J, Schaad I, Schneider E, Seifert B, Burg G, Cassina PC.
Leg ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia.
J Am Acad Dermatol. 2000 Dec;43(6):1001-8.
PMID: 11100015 [PubMed - indexed for MEDLINE]
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Where is the most common location of an ischemic ulcer?
Ischemic ulcers are commonly located on the dorsum of the foot and at the distal tips of the toes.
Hansson C, Andersson E, Swanbeck G.
Location of ulcers on the lower limbs in relation to distal systolic blood pressure indices.
Acta Derm Venereol. 1991;71(6):502-5.
PMID: 1685832 [PubMed - indexed for MEDLINE]
Halperin JL.
Evaluation of patients with peripheral vascular disease.
Thromb Res. 2002 Jun 1;106(6):V303-11.
PMID: 12359343 [PubMed - in process]
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Do you debride an ischemic ulcer?
Ischemic ulcers with no clinical signs of infection should not be debrided.
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Infected ischemic ulcers?
Infected ischemic ulcerations should be debrided, however, vascular consultation should be obtained concurrently.
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What is the mechanism of ischemic ulcer formation?
Atherosclerosis, leading to peripheral arterial disease, is more common in diabetics. Deposition of fatty plaques most commonly occur in the tunica intima of the distal superficial femoral, tibial, and the peroneal arteries. Atheroslcerotic plaque build-up narrows vessels and decreases blood flow to the lower extremities.
Laing P.
The development and complications of diabetic foot ulcers.
Am J Surg. 1998 Aug;176(2A Suppl):11S-19S. Review.
PMID: 9777968 [PubMed - indexed for MEDLINE]
Ramsey DE, Manke DA, Sumner DS.
Toe blood pressure. A valuable adjunct to ankle pressure measurement for assessing peripheral arterial disease.
J Cardiovasc Surg (Torino). 1983 Jan-Feb;24(1):43-8.
PMID: 6833352 [PubMed - indexed for MEDLINE]
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What is the accepted method of treatment for ischemic ulcers?
Patients with ischemic ulcers should be referred to a vascular surgeon for revascularization. Non-invasive arterial study should be ordered to confirm the diagnosis of peripheral arterial occlusive disease and get an idea of the healing potential with the help of toe pressures, ankle brachial index and toe waveforms.
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What type of dressing do you put on an ischemic ulcer?
Wound dressing should keep the wound environment moist, however, if the ulcer has a dry eschar base, the dressing can be dry in order to prevent maceration and subsequent infection.
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What are the appropriate diagnostic tests for ischemic ulcers?
Ankle Brachial Index (ABI), systolic toe pressures, segmental pressures, pulse volume recordings, and photoplethysmography are appropriate diagnostic tests to order in evaluation of ischemic ulcers.
Bone GE, Pomajzl MJ.
Toe blood pressure by photoplethysmography: an index of healing in forefoot amputation.
Surgery. 1981 May;89(5):569-74.
PMID: 7221885 [PubMed - indexed for MEDLINE]
Hafner J, Schaad I, Schneider E, Seifert B, Burg G, Cassina PC.
Leg ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia.
J Am Acad Dermatol. 2000 Dec;43(6):1001-8.
PMID: 11100015 [PubMed - indexed for MEDLINE]
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What is the difference between dry and wet gangrene?
Dry gangrene is an indication of ischemia, whereas wet gangrene is an indication of localized ischemia and infection. Wet gangrene is a surgical emergency. Dry gangrene can be allowed to autoamputate and does not have to be addressed surgically. Patients with dry gangrene should be referred to a vascular surgeon for an evaluation for a revascularization.
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What is normal ABI?
Normal ABI is .9-1.1 Anything less than .9 should be considered abnormal and is consistent with Peripheral Arterial Disease.
However, arterial calcification in patients with Diabetes and orrenal disease may give artificially elevated pressures. Therefore, toe pressures are more commonly used as they are less commonly affected.
Barnes RW, Thornhill B, Nix L, Rittgers SE, Turley G.
Prediction of amputation wound healing. Roles of Doppler ultrasound and digit photoplethysmography.
Arch Surg. 1981 Jan;116(1):80-3.
PMID: 7469736 [PubMed - indexed for MEDLINE]
Carter SA, Tate RB.
Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia.
J Vasc Surg. 1996 Aug;24(2):258-65.
PMID: 8752037 [PubMed - indexed for MEDLINE]
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What toe pressures are consistent with healing?
Systolic toe pressures greater than 55 mmHg are consistent with healing, pressures between 45-55 mmHg are unpredictable, and anything less than 45 mmHg are typically associated with non-healing.
Bone GE, Pomajzl MJ.
Toe blood pressure by photoplethysmography: an index of healing in forefoot amputation.
Surgery. 1981 May;89(5):569-74.
PMID: 7221885 [PubMed - indexed for MEDLINE]
Carter SA, Tate RB.
Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia.
J Vasc Surg. 1996 Aug;24(2):258-65.
PMID: 8752037 [PubMed - indexed for MEDLINE]
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