Vascular Insufficiencies and Ulcers

veins vs arteries

veins have unidirectional valves, are thinner, and have higher compliance as a blood reservoir

arteriosclerosis

thickening/stiffness of blood vessels carrying oxygen and nutrients to the body

most common cause of arteriosclerosis

atherosclerosis

stages of ischemia

early, 1st critical stage, 2nd critical stage, 3rd critical stage

early stage of ischemia

circulatory system compensates by establishing collateral circulation around occlusions in order to maintain peripheral bloodflow

1st critical stage of ischemia

collateral flow insufficient to meet metabolic needs

2nd stage of ischemia

intermittent claudication, chemical pain

3rd stage of ischemia

resting pain, gangrene, nonhealing wounds below occlusion

risk factors for ischemia

high BP, obesity, high cholesterol or triglycerides, smoking, diabetes, family history, age >50

arterial wounds are caused by

chronic or acute impairment of bloodflow, thromboemboli, vasculitis, raynauds, buerger, AV shunt

arterial ulcer chronicity factors

stress, bioburden, MMP, malnourishment, aging

a wound can be chronic

immediately or with lack of perfusion

location of arterial ulcers

tips of toes, between toes, over bony prominences, pressure points from footwear

arteral ulcer wound bed

borders even or represent trauma, dry, pale, no drainage, eschar is possible, deep or superficial

arterial ulcer surrounding tissue

cool to touch (with no infection), pale with elevation, ruddy color with extremity in dependent position, skin thin and shiny

arterial insufficiency/ulcers characteristics

hair loss, shiny skin, muscle atrophy, nails thick/yellow, discoloration of digits, temp difference in opposite limb

arterial evaluation locations to palpate

dorsalis pedis artery and posterior tibial artery

capillary refill test

press at end of toe or proximal to wound until color disappears, normal return of color <3 sec

rubor dependency test

indicative of PAD, extremity raised 30 degrees and checked for pallor, color should return within 15 sec (>30 sec or dark red is positive test)

arterial evaluation tests

arterial doppler, segmental pressures, TcPO2, MRA, CTA, arteriogram

ankle brachial index

average of ankle systolic pressure (either side) divided by the higher of brachial systolic pressure (left or right)

ABI >1/2

possible arterial calcification

ABI 1-1.2

normal peripheral arterial blood flow

0.8 to 1.0 ABI

mild peripheral arterial occlusive disease, refer to vascular

0.5 to 0.8 ABI

moderate PAOD, refer to vascular

<0.5 ABI

severe PAOD, critical limb ischemia

normal toe brachial index

0.8-0.99

healable arterial ulcer

adequate blood supply, cause is corrected, co-factors/conditions/meds ideally optimized/corrected

maintenance arterial ulcer

deemed healable but due to healthcare system factors or patient related issues are preventing wound to heal

nonhealable arterial ulcer

moist interactive healing is contraindicated, debridement is performed on a conservative basis

stable eschar

leave it alone, will take care of itself, protect it

unstable eschar

dry, squishy with palpation, worried about infection - need to treat

unstable eschar with infection

do not touch, consult vascular

before exercising with an arterial ulcer

identify PAD severity first (resting pain = limit exercise, distal LE wound = protect wound)

if PAD and exercise induced limb symtpoms

exercise at an intensity that elicits moderate to intense pain with short breaks for symptoms to subside, progress is rest breaks getting shorter

forces that assist venous return

respiration, calf muscle pump, foot pump, systolic blood pressure

respiration

suction effect created pulling blood back towards the heart

calf muscle pump

deep and perforator veins are compressed, blood is forced proximally if valves are competent

foot pump

venous plexus is compressed and forces blood proximally with ambulation

systolic blood pressure

each contraction pushes blood through the system

medical causes of edema

CHF, DVT, CVI, obesity, renal insufficiency, lymphedema, anasarca, infection, surgery, hip/knee/ankle trauma

differential diagnosis is dependent upon

history, physical and clinical presentation of edema

venous obstruction

result of body's natural response to foreign bodies and causes narrowing of vessel

significance of dysfunction and venous ulceration depends on

where obstruction occurs and how long it lasts

venous thrombosis

begins with platelets adhering to endothelial wall, edema, warmth and LE pain present, risk embolism, valve damage is common

venous dilatation

manifestation of venous HTN (not a cause), varicose veins are permanently dilated from sustained high venous pressure

venous insufficiency

ambulation causes foot and calf muscle pumps to push venous blood from LEs which reduces ambulatory venous pressure - when pump fails pressure increases in veins and ulcers may develop

venous ulcer characteristics

medial lower extremities, hemosiderin staining, wide/large wound, heavy drainage, irregular edges

signs and symptoms of venous ulcer

LE edema, dull ache, heaviness, cramping in legs, pain gets worse when standing or legs in dependent position, pain better with elevation

lipodermatosclerosis

hard, leathery thickening of skin and subcutaneous tissue (upside down champagne bottle)

hemosiderin staining

autolysis of entrapped RBCs and hemoglobin pushed to top layers of skin (change in pigmentation of skin around wound)

venous ulcer treatment

graduated compression - gradual sustained pressure applied to LE to augment the efficacy to calf muscle pump - works best with exercise

elastic/long stretch compression

high resting, low working pressure (may provide excessive pressure on the limb) (greater extensibility and elasticity)

inelastic short stretch compression

low resting, high working pressure (can be applied firmly over joint without causing significant pressure) (limited elasticity and extensibility)

multi-component compression

combination of non-compressive long stretch and short stretch

compression contraindications

acute cardiac edema, renal failure, acute infections, acute respiratory issues, acute DVT, malignancies, arterial insufficiency

<0.8 ABI is commonly taught as a

contraindication for compression

low ABI/weak pulses, apply

low to moderate pressure

3+ pulses, ABI >0.9, apply

high pressure

start bandage application

distally from base of toes ending just below knee bend

if excess wrap is left

cut it

N

number of layers applied

T

bandage tension

C

limb circumference/shape

W

bandage width

higher number of layers

greater the pressure (want more layers distally than proximally)

the greater the tension

the greater the pressure (want more tension at distal segment)

the smaller the circumference

the greater the pressure

the wider the bandage width,

the lower the pressure (smaller bandages at smaller limbs)

compression garments can be used for maintenance once

edema has been adequately managed

<20mmHg compression is

not suitable in management of lymphedema

20-30mmHg compression is

most commonly used

considerations for exercise with venous ulcers

need for compression, focus on calf musculature, CV risk assessment, ROM (edema), gait training with focus on gait pattern