Arterial Ulcer - Causes, Symptoms, and Treatment

Introduction

Arterial ulcers or ischemic ulcers (ischemia means less blood flow) are formed by reduced blood flow to the peripheral areas of the body. Since the blood flow is poor, the oxygen supply to these areas is also reduced, which leads to ulceration and, ultimately, the death of the tissue.

What Is an Arterial Ulcer?

Arteries are blood vessels that carry blood products and oxygen to various body parts. When arteries are narrowed, the blood supply gets restricted, and the skin and tissues of that area are deprived of oxygen. The arterial ulcer usually occurs on the ankles or the toes.

What Are the Causes of Arterial Ulcers?

The causes include:

• Ischemia due to peripheral vascular disease (a disease affecting the blood vessels and causing their narrowing).

• Vasculitis (inflammation of the blood vessels).

• Diabetes mellitus.

• Hypertension (increased blood pressure).

• Arteriosclerosis (blockage of arteries).

• Atherosclerosis (a type of arteriosclerosis causing blocked arteries due to fat buildup).

• Smoking.

• Kidney failure.

• Older adults.

• Trauma.

• Any condition causing restricted movement of the legs.

What Are the Symptoms of Arterial Ulcers?

The arterial ulcers are mostly found on the outer aspect of the feet, ankles, heels, and toes. They have a characteristic ‘punched out’ appearance. They are deep ulcers, often involving the underlying tendons and not showing any signs of bleeding.

The changes observed are:

• The pain usually occurs at night or while exercising.

• Intermittent claudication (pain on walking).

• The color changes to yellow, brown, gray, or black.

• The affected area becomes hairless.

• Nails become atrophic (partial or complete loss of the nail) and darkened.

• Skin becomes dry, thin, and shiny.

• The foot changes to red color while hung down and turns pale when elevated.

• The temperature of the affected area drops down due to the restricted blood supply. It is cold to touch.

• The pulse is not felt in the affected area.

Who Are More Likely to Get Arterial Ulcers?

There are a variety of conditions that increase the risk of developing arterial ulcers. People with the following conditions are more likely to get arterial ulcers:

• Overweight.

• Diabetes mellitus.

• Conditions causing limited movement to the legs.

• Smokers.

• Areas with callus formation due to increased pressure.

• Uncomfortable or ill-fitting footwear that causes more stress on the feet.

• Any condition that limits the blood supply to the feet.

What Are the Diagnostic Aids Available for an Arterial Ulcer?

The diagnosis of an arterial ulcer is usually made by clinical examination and using certain bedside tests.

They are:

Capillary Refill Time - This is not a specific test to find the amount of blood flow. The time taken for the blood vessels to refill following its compression is measured. If it takes longer to refill, it indicates inadequate blood flow.

Buerger Test - The patient is made to lie down and lift their leg at a 45-degree angle to the floor. If the foot becomes pale upon elevating and bright red on lowering, it indicates insufficient blood flow.

Ankle-Brachial Index - It is the ratio of the highest blood pressure at the ankle to the arm. A value of less than 0.9 indicates arterial insufficiency.

Toe Brachial Index - It calculates the highest right or left toe blood pressure ratio to the highest pressure of the arms. This index measures the amount of blood supply in that area.

Transcutaneous Oximetry - It measures the oxygen content of the skin around the wound. Values less than 40 mmHg indicate arterial insufficiency.

What Are the Treatment Options for an Arterial Ulcer?

The treatment of an arterial ulcer aims to improve the blood supply and promote the healing of the ulcer.

Medications - The underlying medical conditions are first treated to prevent the cause of arterial insufficiency. Hypertension (high blood pressure), diabetes, and cholesterol levels are brought to normal levels by prescribing appropriate medications.

Angioplasty - Angioplasty is a procedure wherein a balloon catheter (a long tube) is inserted into the blood vessel and unclogs the blocked or narrowed artery.

Stenting - A tube inserted into the blood vessel that has been opened and prevents it from narrowing again.

Atherectomy - It has a catheter with a blade at one end. The catheter is inserted into the blood vessel, and the blade removes the plaque inside the artery. This procedure is done when the other two treatments fail to heal the blood vessel.

All the Procedures have a Common Goal: Remove any blocks in the artery so that it can function normally for good blood flow to the area of the arterial ulcer.

How to Take Care of the Wound?

The following are the instructions for proper wound care after the surgery.

• The dressing for the wound must be changed regularly by themselves or by the caretaker.

• The wound is kept clean and covered with a bandage.

• The area around the wound should be dry. If the surrounding area is wet, the wound infection can spread and become more extensive.

What Are the Complications of an Arterial Ulcer?

The complications occur if the arterial ulcer is unnoticed and is left untreated for a long time. Tissue necrosis (death of the tissue) or amputation (removal of a part of the feet) can occur when the infection becomes more extensive. Hence, the patient must consult the doctor immediately to prevent such circumstances.

How to Prevent an Arterial Ulcer?

The following precautions are followed to prevent the risk of developing an arterial ulcer or minimize the complications.

• The patient has to maintain blood pressure, blood sugar, and cholesterol levels.

• Patients with smoking habits must quit.

• The feet are examined regularly for any changes in color or the presence of an ulcer.

• Avoid wearing ill-fitting footwear and tight elastic socks.

• The patient must avoid standing for a long time.

• Try to protect feet from the cold.

• Soaking the feet in warm water is usually avoided.

• Avoid sitting with the legs crossed.

• Wash the feet properly to prevent any infection.

• Exercises are performed every day as per the physician's recommendation to increase blood flow.

Conclusion

Arterial ulcers are formed in areas of poor blood supply. Hence, re-establishing the blood flow through various treatment modalities remains the mainstay of the treatment. With adequate blood flow, arterial ulcers usually heal unless there are any associated complications.