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Topics

Normal arterial perfusion and terms

Etiology

• Atherosclerosis
• Arterial trauma
• Acute embolic syndrome
• Entrapment syndromes
• Buerger’s Disease (thromboangitis obliterans)
• Sickle cell
• Associated with autoimmune diseases, collagen abnormalities, vasculitic disorders, clotting abnormalities such as protein C deficiencies and vasospastic diseases such as Raynaud’s disease.

Pathology of atherosclerosis

Risk Factors

• Modifiable:
  • Tobacco use
  • Hypertension
  • Dyslipemia
  • Diabetes
• Predisposing:
  • Advanced Age
  • Male gender
  • Family history
  • African American ethnicity
• Emerging:
  • Hyperhomocysteinemia
  • Increased C-Reactive Protein
  • Chronic renal disease
  • Chlamydia pneumoniae
  • Peridontal disease

Arterial disease and diabetes

Structured assessment approach

• Patient assessment
• Pain history and assessment
  • Common locations, characteristics, alleviating and aggravating factors
  • Intermittent Claudication
  • Nocturnal
  • Rest
• Lower extremity exam
  • General appearance of limb
  • Ischemic Skin Changes
    • Epidermal thinning
    • Atrophy of subcutaneous tissue
    • Shiny, taut, dry skin
    • Purpura
    • Loss of hair
    • Thick toenails
  • Color changes
    • Elevational pallor
    • Dependent rubor
  • Assess pulses
  • Doppler signal quality
  • Ankle-Brachial Index
  • Skin temperature
  • Capillary refill
  • Non-invasive assessment
    • TBI
    • Transcutaneous oxygen
• Focused wound assessment

Ulcer characteristics and pathology

• Location: Distal aspect of extremity, phalangeal heads, lateral malleolus, areas of repetitive trauma
• Punched out appearance, well defined borders
• Pale or necrotic wound bed
• Minimal exudate
• Faint halo of erythema, infection common
• Extremely painful

Treatment

• WOCN guidelines: Relate treatment to adequacy of perfusion (ABI).
• Referral to vascular surgeon: surgical/endovascular options
  • Limb salvage/preservation
  • Bypass grafts
  • Angioplasty
  • Thrombolysis
  • Amputation
• Pharmacologic options
  • Analgesics
  • Risk factor modification
    • Statins
    • Antiplatelet agents
    • Cilostazol
• Referral indications
• Adjunctive therapies
  • Hyperbaric oxygen therapy
  • Arterial flow augmentation
• Measures to improve perfusion
  • Smoking cessation
  • Maintenance of hydration
  • Avoidance of cold
  • Avoid caffeine
  • Avoid constrictive garments
  • Graduated walking program
  • Nutritional supplements

Topical Management Issues

• Identify and treat infection
• Maintain dry non-infected necrotic wound
• Cleansing.
• Cautious use of occlusive dressings
• Manage edema in mixed disease
• Principles
• Appropriate use antiseptics and topical antibiotics
• Pain management
• Indicators of wound infection in the ischemia limb.

Patient education

Summary​