Practice Essentials
Chronic leg or vascular ulcers typically manifest as arterial, neurotrophic, or venous ulcers. They are distinct with regard to their location, appearance, bleeding, and associated pain and findings.
Ulcers of the lower extremities, particularly in individuals older than 65 years, are a common cause for visits to the podiatrist, wound care specialist, primary care physician, vascular surgeon, or dermatologist.
The great majority of vascular ulcers are chronic or recurrent. They cause a considerable amount of morbidity among patients with peripheral vascular disease, including work incapacity. The care of chronic vascular ulcers places a significant burden on the patient and the health care system. Additionally, these nonhealing ulcers place the patient at much higher risk for lower extremity amputation.
Workup of vascular ulcers
Imaging studies
When noninvasive tests reveal unacceptable pedal perfusion, perform imaging studies of the lower extremity to identify the level of obstruction and to evaluate the distal runoff.
Perform angiography when visualization of the vessels of the lower extremities is desired. A femoral runoff analysis is the study of choice. Magnetic resonance angiography (MRA) can also be useful when evaluating lower extremity disease.
Doppler duplex scanning can detect venous reflux with a sensitivity greater than 75%, compared with approximately 40% for descending venography. Ascending venography also may be considered to obtain detailed anatomic information.
Other tests
Ankle-brachial indices (ABIs) and toe digital pressures with pulse volume recordings can provide good clues to the perfusion of the foot.
Xenon-133 clearance to measure blood flow can help to estimate the chance of wound healing.
Transcutaneous oxygen tension may be measured; however, a wide discrepancy exists with the minimal level below which wound healing does not occur. Most agree that a pressure of 30-35 mm Hg is sufficient for healing of more than 90% of wounds.
Management of vascular ulcers
Medical therapy
Research on wound care has resulted in increased use of interactive and active dressings rather than passive dressings that cover and absorb. Interactive hydrocolloid dressings provide a controlled microenvironment for wound healing. Active dressings deliver substances such as growth factors, which are important in the healing cascade.
Surgical therapy
When determining whether to perform surgical therapy for chronic vascular ulcers, consider which is more appropriate for the patient: (1) revascularization and/or coverage of the wound, (2) ligation of incompetent venous perforators, or (3) primary amputation and rehabilitation.
When the ulcer is caused by venous reflux in the superficial venous system, the problem can be addressed with minimally invasive procedures commonly practiced by vascular surgeons. These surgeries include saphenofemoral junction disconnection, stripping of the long saphenous vein to below the knee, calf varicosity avulsions, and saphenopopliteal junction disconnection. The rate of wound healing for those treated with surgery is not significantly higher than that of patients who are treated conservatively, but the resultant diminished rate of wound recurrence is a benefit.
Ligation of superficial venous perforators has been shown to reduce the 4-year recurrence rate of vascular ulcers, from 56% in ulcers treated by compression alone to 31% in ulcers treated by compression plus surgery.
Revision of the wound followed by split-thickness skin graft (STSG) has long been an option for chronic wound management. Often, however, the wound bed is not suitable for grafting or a structure such as a bone or tendon is exposed. Under these circumstances, consider pedicled or free flaps. Microvascular flap coverage of chronic ulcers has met with much success in the treatment of arterial ulcers.