Ulcers

What is a leg ulcer?

It is a break in the skin which allows air and bacteria to get into the open wound. Leg ulcers are chronic sores that can take weeks to months to heal. They often develop on the inside of the leg, just above the ankle.

What causes leg ulcers?

Venous and arterial diseases cause leg ulcers. 80% of leg ulcers are caused by venous insufficiency. 15% are cause by arterial insufficiency. 5% are caused by diabetes, rheumatoid arthritis and several rare conditions.

The Dangers of Peripheral Artery Disease (PAD)

About one in 20 people over age 50 have some level of peripheral artery disease. The danger from peripheral artery disease is that it indicates other circulatory problems. In fact, it may be the first warning sign of atherosclerosis. PAD puts the entire circulatory system at risk. Patients with PAD are at risk for coronary events like heart attack, stroke, and death. Organs supplied by the affected vessels may not get enough blood to work properly. People with coronary artery disease often also have PAD. The mortality associated with PAD is high- up to 30% mortality risk at 5 years. PAD is not often recognized by a patient or diagnosed by a physician, despite being easily diagnosed. Many patients have no symptoms. Those patients with diabetes are at particular risk of death. This is where you need an expert who can accurately diagnose and treat you.

Characteristics and risks

Venous ulcers and arterial ulcers have different characteristics and risk factors.

1. Venous ulcers

Appearance

  • Superficial
  • Irregular in shape
  • Painful due to edema, phlebitis or infection
  • Usually appear on the lower leg and ankle, and
  • Often contact dermatitis develops

Risk factors

Deep vein thrombus, congestive heart failure, varicose veins, poor calf muscle function, obesity, immobility and pregnancy.

Causes

  • Atherosclerosis, the buildup of plaque inside the blood vessels.
  • Chronic Venous insufficiency due to vein valve damage.
  • A deep vein thrombus or blood clot that blocks blood from circulating.
  • Phlebitis is a blood clot in an inflamed vein that results in pooling of the blood, injury to the vein and changes how the blood clots.

Treatment

The first goal is to identify the cause and address it. To treat the ulcer, conservative compression therapy is the standard of care. Venous ulcers heal faster. Leg elevation of the affected limb minimize edema, improves circulation and aids healing. Debridement or removal of dead, damaged and infected skin enhances healing. Venous leg ulcers often become infected and will be treated with antibiotics.

2. Arterial ulcers

Appearance

  • Thick, bright red granulation tissue
  • With a punched out appearance and smooth edges
  • Painful at night
  • Found most often on the lateral foot, but
  • Can be found anywhere on the lower leg and foot
  • Lower legs feel cool to the touch
  • Skin is shiny, taut and thin
  • Loss of hair growth on lower limbs
  • May be due to peripheral arterial disease
  • Often results after a trivial trauma

Risk Factors

Chronic vascular insufficiency, atherosclerosis, uncontrolled diabetes, limited joint mobility, structural foot abnormalities, kidney disease, a history of ulcers, risk increases with age.

Symptoms

the most common symptom is claudication (tiredness in the leg or hip muscles while walking and climbing stairs). Often the pain goes away with rest, and returns with walking. As symptoms progress pain or ulceration can occur. These advanced signs can lead to gangrene and amputation. Patients with pain while at rest, and a non-healing ulcer should be seen by a vascular surgeon.

Causes

Arterial Ulcers are caused by reduced arterial blood supply to the extremities which results in tissue damage. Reduced blood supply is usually due to atherosclerosis. Diabetes and other disease also cause arterial ulcers. Development of blood clots and blockage contribute to ulcer formation. Infection can cause arterial ulcers to rapidly deteriorate so antibiotics will be recommended.

Treatment

For all patients with PAD, reducing cardiovascular morbidity and mortality are a primary concern. The objective is to increase blood flow to the legs, and restore function. There are several time tested treatments that are most effective to promote healing. Recommendations to improve blood flow also include controlling diabetes, stopping smoking, controlling hypertension and hyperlipidemia. Most patients with claudication can remain stable with medical therapy.

Treatment must be individualized. Surgical revascularization is indicated in patients with acceptable surgical risk, including consideration of the patient’s comorbidities. Antiplatelet therapy with stenting improves outcomes. Indications for lower extremity revascularization are acute limb ischemia, critical limb ischemia (indicated by rest pain, non-healing leg ulcers and claudication.

  • Claudication – a lifestyle limiting symptom is characterized by lower extremity rest pain, ulceration and gangrene due to deficient blood supply. Treatment is intended to improve functional status and reduce leg amputation.
  • Tissue loss – ulcers must be treated to prevent infection and loss of limbs
  • Pain at rest – due to diminished blood flow must be treated.

Minimally invasive procedures include:

  • Percutaneous angioplasty- a minimally invasive procedure. A catheter, which is a small hollow tube, is commonly threaded through the groin vessel to the affected artery.  There are several kinds of catheters, this one has a non-inflated balloon at the tip of the catheter.  When it reaches the diseased artery, the vascular surgeon inflates the balloon to flatten the plaque into the arterial wall.  The objective is to increase blood flow. Often times, a stent may be inserted into the diseased artery to keep vessel open.
  • Catheter directed thrombolysis. Removal of a clot in the leg artery is the recommendation for initial treatment of patients with acute limb ischemia. Patients with a high risk of bleeding are not candidates. It can reduce the need for immediate surgical intervention. Simultaneous treatment with percutaneous angioplasty may be indicated.
  • Peripheral Endarterectomy. The surgical removal of arterial plaque in a peripheral artery. Candidates for this procedure are at greater risk of stroke or heart attack, so your physician may order additional tests.
  • Bypass grafting. A graft is used to bypass or replace the diseased vessel. The diseased blood vessel is removed and a healthy section of blood vessel or a man-made graft is used.
  • Laser therapy. Low level laser therapy improves cellular repair and stimulates the immune, lymphatic and vascular systems. The application of low level laser therapy accelerates healing of venous leg ulcers.
  • Jetstream Atherectomy. This is endovascular therapy, meaning it is a minimally invasive catheter-based removal of plaque from the artery, to increase blood flow. The plaque is due to atherosclerosis. If left untreated, gangrene and amputation will follow.
  • At BASS, we use the FDA approved Spectranetics Excimer laser for Atherectomy. This laser Atherectomy procedure removes blockages that cause ulcers by creating a channel for blood flow in diseased and blocked arteries. We may also use stents from Boston Scientific to reduce restenosis, and support revascularization and maintain the new channel for blood flow.

The physicians at BASS are experts in the treatment of leg ulcers and offer state-of-the-art technologies to address wound healing.