woundFOCUS
Arterial Ulcers
What?
Arterial ulcers are wounds or breakdowns in the skin that occur when an injury occurs to an area with a lack of blood flow. Not enough blood means that the wound can’t heal, which can be painful and make infections and amputations more likely.
Why?
Disease of the arteries is caused by injury and inflammation in the vessel wall. This injury is usually a result of smoking, age, diabetes, high cholesterol and high blood pressure.
What Can Be Done?
After a thorough history and examination, if arterial ulcers are suspected it is important to obtain imaging of the arteries of the leg to determine if there is any disease. This is usually done with ultrasound or CT scan.
What needs to be done depends on the result of these scans. No matter what they show, the first line of treatment involves lifestyle modification and medications. Exercising 30 minutes three times a week, improving diet, ensuring adequate blood sugar levels and ceasing smoking are important lifestyle modifications that will improve your arterial health. Medications that lower your cholesterol called statins will most likely be prescribed, as will a blood thinner such as aspirin. If your blood pressure is high suggestions will be made to improve this as well. Any diabetic medication will need to be adjusted to ensure your blood sugar levels are improved. All these interventions will improve both your legs AND your risk of heart attack or stroke
Depending on what these scans find, it may be necessary to perform an operation to improve the blood flow and help heal the ulcer. Operations can take the form or keyhole procedures that use balloons and stents to open up the diseased vessel or open procedures that bypass around the diseased vessel.
While keyhole or “endovascular” treatment is preferred, this is not always possible or may not be the best option given your specific circumstances. The best course of treatment can be a complex problem and this will be discussed with you in detail at your appointment.
Venous Ulcers
What?
Venous ulcers occur in the lower legs of people with incompetence or blockage of their veins.
Why?
The exact mechanism by which venous ulcers occur is poorly understood, but is likely secondary to a complex interplay of factors leading to inflammation and skin breakdown. Elevated pressures in the tissues caused by the veins not working causes this inflammation.
What Can Be Done?
The majority of ulcers heal with simple measures such as dressings, compression bandaging and elevation.
If there is any superficial vein incompetence that may be contributing to the ulcers, this can be treated with an operation. This will heal your ulcers more rapidly and they will be less likely to recur.
If you have recurrent ulcers and there is obstruction in the veins in your pelvis, a stent may improve the flow and help to heal your ulcers. This is specialised surgery and requires careful consideration.
Diabetic Foot Ulcers
What?
Diabetic foot ulcers occur on load bearing areas of the feet. They are a common and serious condition in diabetics - mainly older patients and those with poor blood sugar control. Ulceration can lead to infection, a limb threatening emergency.
Why?
Diabetes causes many changes to the normal physiological mechanisms that act to prevent or heel foot injuries. Nerve damage (neuropathy) reduces the ability of the sufferer to feel injuries when they occur. Arterial disease reduces healing. Diabetes also changes the structure of the foot resulting in areas of the foot experiencing increased pressure levels, making damage more likely.
What Can Be Done?
Diabetic foot ulcers require intense care from a multidisciplinary team of healthcare professionals. Vascular surgeons, endocrinologists, podiatrists, dieticians and wound care nurses are all important stakeholders in wound treatment.
Dr Werner-Gibbings has extensive experience in treating diabetic ulcers and works closely with his team to improve results. At your consultation Dr Werner-Gibbings will undertake a thorough history and examination. He will review any blood and imaging results. If the wound looks infected he may need to admit you to hospital for antibiotics and debridement.
Treatment will consist of ensuring your medications and blood sugar control are optimal. This may require referral to a endocrinologist. The ulcer will need regular dressings and special footwear will be required to offload any pressure areas. If there is any arterial disease, this may need to be treated to maximise healing. Even with the best of care, amputations can be necessary.
Once the ulcer is healed, expert foot surveillance is essential to prevent further ulcers, as recurrence is a frequent complication. You will frequently follow up with Dr Werner-Gibbings and a podiatrist to ensure ongoing foot health.
A detailed description of venous ulceration and treatment is available from the ANZ Society of Vascular Surgery via the link below