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Arterial vs venous ulcers: Diagnosis and treatment - source VASCULAR ULCERS
Because both arterial and venous ulcers typically occur on the lower leg, differentiating between them can be challenging for wound care practitioners. However, they have very different pathophysiologies and management pathways.
A careful and accurate assessment of the vascular status is essential when a patient presents with a chronic wound on the lower leg or foot. This assessment will help to determine if the patient has arterial disease, which is generally a contraindication to compression therapy, the cornerstone of venous ulcer management. Noninvasive diagnostic options for arterial assessment include manual palpation of pulses, Doppler examination, venous duplex ultrasonography, and plethysmography.
The following discussion provides information on the distinguishing characteristics of arterial and venous ulcers to assist the practitioner in making management decisions.
Arterial Ulcers
Arterial ulcers result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus, trauma, or advanced age. Pain, with exercise, at night, or while one is resting, is often the most distinguishing characteristic of arterial ulcers. Determining the anklebrachial index (ABI) will give an indication of a patient's ability to heal. However, diabetic patients may have falsely elevated ABI results secondary to vessel calcification.
Patients with arterial ulcers must have increased/adequate blood supply to heal and benefit most from revascularization procedures.
Characteristics of arterial ulcers
- Present almost anywhere on the leg; usually distal to impaired arterial supply, between toes or tips of toes, over phalangeal heads, around lateral malleolus, or at sites subjected to trauma or rubbing of footwear.
- Wound margins are even, sharply demarcated, and punched out.
- Wound may be superficial or deep.
- Wound beds may be pale, gray or yellow with no evidence of new tissue growth; necrosis or cellulitis may be present; commonly accompanied by dry necrotic eschar and exposed tendons.
- Have minimum exudate.
- Periwound tissue may appear blanched or purpuric and is often shiny and tight; loss of hair at ankle or foot.
- Usually very painful; pain is often relieved by dependent leg position and aggravated by elevation.
Venous Ulcers
Venous ulcers result from valve incompetence in perforating veins, a history of deep vein thrombophlebitis and thrombosis, a failed calf pump, obesity, age, or pregnancy in women with a family history of venous ulcers.
Healing is best expedited by increasing venous return, decreasing edema, appropriate compression, and proper skin and wound management.
Characteristics of venous ulcers
- Occur anywhere between the knee and the ankle, with medial and lateral malleolus the most common sites.
- Usually are superficial.
- Wound beds vary in appearance, frequently ruddy, beefy red, granular tissue; calcification in wound base is common; a superficial fibrinous gelatinous necrosis may occur suddenly with healthy appearing granulation tissue underneath.
- Have moderate to heavy exudate.
- Tend to be large with irregular margins.
- Surrounding skin is characterized by hyperpigmentation, dermatitis, and lipodermatosclerosis.
- May be painless; however, pain varies unpredictably and often is relieved with leg elevation.
The algorithms on the next page offer options for managing patients with arterial or venous ulcers. Care should be individualized to the patient's specific conditions as needed.
INTERPRETING ANKLE-BRACHIAL RESULTS
Use the following guideline to interpret the ABI results:
- 0.9 to 1 -normal
- 0.75 to 0.9-moderate disease
- 0.5 to 0.75-severe disease
- below 0.5-limb-threatening disease.
useful links
Venous Ulcer Venous leg ulceration Arterial leg ulceration Ankle-brachial index Ankle brachial pressure index
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