1 Arterial Leg Wounds

What are Risk Factors for PAD?

• Age 65+

• Age 50-64 with risk factors for atherosclerosis (DM, smoking hx, dyslipidemia, HTN), CKD, family history PAD

• Age< 50with DM+ 1 more atherosclerosis risk factor

• Persons with known atherosclerotic disease in another vascular bed

what are Foot Wound Risk Factors in People with PAD?

• Previous foot wound or amputation

• Charcot foot

• DM with poor glycemic control

• CKD (chronic kidney disease)

• Peripheral neuropathy

• Corns or callouses

• Ongoing smoking

What does arterial leg wounds look like?

• Thin, Shiny, dry skin

• Hair loss on ankle and foot

• Dystrophic (thick) or yellow toenails

• Elevation pallor

• Dependent rubor

• Decreased temperature

• Absent or diminished pulses

• Cyanosis

• Ischemic pain

what anatomical locations are common with arterial leg ulcers?

• Typically at foot and malleoli

  • Between toes

  • Tips of toes

  • Pressure points (heel or lateral foot)

  • Sites of trauma or footwear rubbing

What the typical presentation of arterial leg wounds?

• Location: distal to ankle, usually at foot and malleoli, sites of pressure from footwear, trauma, pressure

• Wound base: pale or necrotic

• Wound edges: well-defined, “punched out”

• Periwound: thin, shiny, may be blanched or purpuric; hair loss and nail changes common

• Pain: often severe, commonly worse with limb elevation

What are subsets of LE PAD?

• Asymptomatic PAD

• Symptomatic PAD

• Critical limb-threatening ischemia

• Acute limb ischemia

What past medical history could affect a PAD foot exam?

• Previous ulcer/ischemia, amputation, deformity callous

• Current PAD/ischemia/wound symptoms

• Tobacco use

• Diabetes

• Retinopathy

• CKD

• Neuropathy

What should be examined in a PAD foot exam?

• Skin integrity

• Foot deformity

• Sensory: 5.07 with 1 additional (sharp, temp, or vibration)

• Pulses legs and feet

What should be screened in a PAD foot exam?

• Footwear

• Foot hygiene

• Physical limitations to foot self-care

• Does patient know components and perform foot self-care?

how do we test for arterial insufficiency?

• Vascular testing

  • ABI

  • Arterial ultrasound if ABI < 0.6

    • speak with primary care provider about results

    • ask for vascular surgery consult

  • Toe brachial index if ABI >1.4

• Buerger's test:

  • elevate limb 45 degrees for 1-2 minutes, observe, place in dependent position

when performing an ABI for arterial ulcer management, if the ABI is <.6, we should use an _______, and if the ABI is >1.4, we should use the ______

• arterial ultrasound

• toe brachial index

How do you prevent PAD wounds?

• Foot self-care education

• Foot inspection every health care visit

• Therapeutic foot wear for high risk patients

• Comprehensive foot evaluation yearly

• Referral to a foot specialist when available

How do you care for a PAD wound?

• Protect and offload area.

• Sharp debridement of nonviable tissue as indicated. Leave any stable, dry eschar in place.

• Appropriate dressings. For stable, dry eschar, apply povidone iodine and gauze.

• Monitor for infection.

• Control edema as able

How should PAD wound management by Medical Team look like?

• Vascular surgery referral

• Management of infection and/or inflammation

• Pain control

• Smoking cessation

• Glycemic control

What should be considered for CLTI(Chronic Limb-Threatening Ischemia) where surgery is not an option?

Arterial intermittent pneumatic compression

When you find Gangrene in outpatient or non-acute setting, what is the next step?

Obtain urgent referral to vascular surgeon, be in communication with primary physician and document this. Consider ER if gangrene moist or worsening (i.e. toe turning purple)

When you find Gangrene in acute setting, what is the next step?

notify physician, ask to order arterial ultrasound & vascular surgery consult

What is the goal for managing Arterial ulcers?

minimizing tissue loss; if possible, intact skin surface on a functional foot

what lifestyle and exercise programming should be done for arterial ulcer management?

• Exercise in a home or community setting, prescribed by appropriate health care provider, with careful consideration to wound location

• Patients who smoke should be counseled at every visit to quit and referred to smoking cessation program

what may the patient deal with if they have mixed venous and arterial insufficiency?

neuropathic, trauma and pressure

what is the treatment for mixed vascular disease?

• Treat the cause if possible

  • Ask for referral to vascular surgeon.

  • No compression bandaging if ABI ≤0.5

• Local Wound Care