When a Wound is not Just a Wound: Arterial Wounds and Ischemic Ulcers

Sarah S. was an 88-year-old fiercely independent woman with severe but stable peripheral arterial disease (PAD, or blockages in the leg arteries). She used a walker but lived alone and adamantly refused any help in her Manhattan apartment. Whenever a visiting nurse came to see her, she promptly discharged the nurse. She was getting along fine until she developed a break in the skin on the outside of her second toe, probably because one of the neighboring toenails was rubbing on it. The poor circulation in her leg prevented the sore from healing. A few days later, the skin on the third toe broke down as well because it was constantly wet and rubbing on the other adjacent sore toe. With arterial wounds on her toes, presumably due to her PAD, Sarah now required urgent evaluation by a vascular specialist to avoid losing her foot/leg. Vision problems and arthritis interfered with Sarah's ability to care for her wounds, so she finally agreed to a visiting nurse. She was fortunate: the wounds eventually healed with the help of her vascular doctor, her podiatrist and excellent nursing care.

Arterial wounds (sometimes called ischemic ulcers), are breaks in the skin or sores, usually found on the toes or feet or rarely on the fingers. Poor circulation causes the tissue to die and prevents these wounds from healing. In contrast to venous ulcers, which often occur on the inside of the lower leg and ankle, arterial ulcers are typically on the tips of toes, between the toes, on the outside of the ankle, or over bones at points with the least amount of blood flow. The wounds may start due to minor injuries or pressure from shoes that do not fit well. Arterial ulcers are quite painful unless surrounding nerves have been damaged, such as with diabetic neuropathy.

While anyone may develop a wound on the foot, it is not considered an "arterial" problem unless blood flow to the area is reduced. Thus, vascular testing is necessary to make the diagnosis. The ankle-brachial index (ABI) is the most commonly used test to diagnose PAD, or poor circulation. It involves placing blood pressure cuffs on the ankles and on the arms to check the blood flow. This test, along with others offered in a vascular laboratory, can be useful for determining the cause of a wound as well as predicting its ability to heal.

Once an arterial wound is diagnosed, the most critical aspect of treatment is to restore blood flow to the affected area. Restoration of blood flow may involve either 1) opening the blocked artery with balloons and catheters and at times with stents ("endovascular revascularization"), or 2) surgical treatment, such as bypass grafting. Other important aspects of treatment involve eliminating the initial inciting factor (such as the poorly fitting shoes which caused the ulcer in the first place), treating the wound itself, and protecting it. Arterial wounds are typically kept dry until the blood flow is restored. Antibiotics, topical medicines, and/or dressings may be prescribed depending on the wound. Smoking cessation is crucial because smoking interferes with wound-healing. Good nutrition and appropriate pain management are also vital. With arterial ulcers, there is always a risk of amputation. Thus, early diagnosis and treatment are essential.

Prevention of arterial wounds, what you can do:

• Meticulous foot care is important, particularly among people with PAD or diabetes.
• Wear shoes that provide support without causing pressure points.
• Clean your feet well and dry between the toes to prevent skin breakdown.
• Carefully inspect your feet on a regular basis (if you are unable to do this, have a family member do this for you).
• If your nails are thickened or if there are other foot issues, you should see a podiatrist to assist with routine foot care.
• Keep your diabetes under control if you have it.

The majority of people with PAD never suffer from an arterial wound. However, if you have PAD and you develop a sore, it is absolutely essential to let your doctor know right away so that proper treatment can be implemented. Similarly, if anyone develops a wound that does not heal in a reasonable amount of time, the circulation should probably be checked to ensure that the area is receiving adequate blood supply.

About the Author: Elizabeth Ratchford, MD, is an Assistant Professor of Medicine at the Johns Hopkins University School of Medicine in Baltimore, Maryland. She is also the Director of the Johns Hopkins Center for Vascular Medicine in the Division of Cardiology.