Arterial

Recommendations

Identify and Treat the Cause
1 Take a careful history and conduct a physical inspection. Level of Evidence
Not Assessed
2 Use appropriate vascular investigations to delineate the extent of stenoses and occlusion and provide information for revascularization. Level of Evidence
Not Assessed


Address patient-centered Concerns
3 Provide patient education about lifestyle modification that may reduce the risk of additional cardiovascular events. Level of Evidence
Not Assessed


Provide Local Wound Care
4 Implement aggressive risk factor management in patients with arterial ulcers. Level of Evidence
Not Assessed
5 Arterial ulcers should be kept dry. Level of Evidence
Not Assessed
6 Address patient factors that may be contributing to delayed healing. Level of Evidence
Not Assessed
7 After revascularization, use normal wound care strategies for ulcer healing. Level of Evidence
Not Assessed
8 Paint wound with low toxicity local anticeptic to dry out the wound and decrease surfact bacteria. Level of Evidence
Not Assessed


Provide Organizational Support
9 Establish and empower an interprofessional team to maximize healing. Level of Evidence
Not Assessed


Background

Arterial ulcers result from inadequate perfusion of skin and subcutaneous tissue, and they are primarily a complication of peripheral arterial disease (PAD). A punched-out appearance, with a pale, dry poorly perfused base is characteristic of arterial ulcers. The foot and leg may be cold, pale or bluish, with shiny, taut skin and dependent rubor, and possibly gangrenous toes. Pain is commonl, especially after exertion or leg elevation. A decreased ankle-brachial index (ABI) confirms the diangosis. Arterial insufficiency may be slowly or rapidly progressive, and early diagnosis is critical to prevent further tissue death.

Revascularization is an important treatment option for non-healing arterial ulcers or in the presence of gangrene, rest pain or progression of claudication. Referral should be made to a vascular surgeon for possible angiography and surgical management. Not only can revascularization allow arterial ulcers to heal but also it can reduce the high risk of further ischemia, gangrene and limb loss. Candidates for revascularization may have significant systemic atherosclerosis and a high risk of cardiovascular events and surgical morbidity. As a result, modifiable cardiovascular risk factors should ideally be addressed before planning revascularization surgery. Patient factors that may contribute to delayed healing include comorbid conditions, nutrition, edema, and pressure.

Revascularization approaches:
· Aortoiliac system: Aortoiliac reconstruction with aortofemoral bypass remains the gold standard, with an 80–85% 5-year patency. Less invasive approaches, including percutaneous balloon angioplasty, possibly with stenting, may be appropriate for unilateral iliac disease or in critically ill patients. Bypass procedures can now also be performed endovascularly, and laser surgery may be available.
· Femoral-popliteal-tibial system: Femoropopliteal bypass using the saphenous vein achieves 75–85% 5-year patency. Reconstruction of the arteries below the knee using the saphenous vein can achieve 70% 5-year patency. Endovascular interventions in these vessels are not yet as successful as those in the aortoiliac system. New technologies may, however, allow these minimally invasive techniques to heal wounds, salvage limbs, or provide a bridge to reconstructive surgery.

As arterial ulcers tend to be dry, the wound should be kept moist to prevent additional cell death and necrosis. Infection must always be considered, but it is uncommon until perfusion is restored. After successful revascularization, normal wound care approaches generally result in healing of arterial ulcers. Infection can cause rapid deterioration, and treatment may require systemic antibiotic therapy and surgical debridement.

Patient education, lifestyle changes and medical management are critical in addressing atherosclerotic risk factors. Smoking cessation and medical and lifestyle management of dyslipidemia, hypertension and hyperglycemia can substantially reduce cardiovascular risk. It is also important to address patient factors, such as nutrition, that may delay healing.

References

Essential Publications
1 Outcome measure - complete ulcer healing in patients with critical limb ischemia Quality Indicator
 Type: Systematic review
Hoffmann U, Schulte KL, Heidrich H, Rieger H, Schellong S. Complete Ulcer Healing as Primary Endpoint in Studies on Critical Limb Ischemia? A Critical Reappraisal, 2007, European Journal of Vascular and Endovascular Surgery, 311-316.
This well-designed systematic review of cohort studies was conducted to evaluate the figures for complete healing rates and healing rates in revascularization studies in patients with critical limb ischemia that was assess the value of the endpoint in studies on reconstructive measures. Complete ulcer healing is not a consistently reported criterion for success of revascularization in critical limb ischemia. The study illustrates the importance of using a consistent outcome measure in intervention studies, similar to clinical practice.
2 Low-frequency Ultrasound therapy – Ischemic wounds Quality Indicator
 Type: RCT
Kavros, Steven J. DPM, FAPWCA; Miller, Jenny L. PT; Hanna, Steven W. MPT . Treatment of Ischemic Wounds with Noncontact, Low-Frequency Ultrasound: The Mayo Clinic Experience, 2004-2006. Advances in Skin & Wound Care. 20(4):221-226, April 2007.
In this open-label RCT conducted to evaluate the clinical effectiveness of MIST Therapy in the treatment of ulcers associated with chronic critical limb ischemia, 35 patients received MIST therapy plus standard care, and 35 patients formed a control group that received standard care for 12 weeks or until fully healed. Most patients had a history of smoking, and the mean age was 75 years. 63% of patients who had MIST therapy compared with 29% of the control group achieved more than 50% healing (P<0.001). Despite lack of a) details of randomization, b) blinded assessments, and c) reporting of withdrawals/dropouts, this study suggests that the addition of MIST therapy improves healing of ischemic leg ulcers.
3 Bypasses Quality Indicator
 Type: Narrative Review
Lazarides MK, Giannoukas AD. The role of hemodynamic measurements in the management of venous and ischemic ulcers. Int J Low Extrem Wounds; 2007: 6(4) 254-261.
Contrast arteriography of the abdominal aorta and branches remains the gold standard for the anatomic diagnosis of arterial disease. CFDI quantifies any proximal disease and the degree of involvement of distal vessels that may be possibly used for distal bypass grafting. In a recent study, preoperative Color Flow Doppler Imaging (CFDI) was equally effective as arteriography in selecting the target vessel for distal anastomosis in patients undergoing bypass to the tibial arteries.
4 Bypasses Quality Indicator
 Type: Narrative Review
Natale A, Belcastro M, Palleschi A, Baldi I. The Mid-Distal Deep Femoral Artery: Few Important Centimeters in Vascular Surgery. Ann Vas Surg; 2007: 21 111-116.
The deep femoral artery is an important artery in lower-limb revascularization. This review highlighted the importance of the mid-distal deep femoral artery (MD-DFA) both as an outflow and as an inflow site for peripheral bypasses.
5 Bypasses Quality Indicator
 Type: Retrospective Analysis
Tefera G, Hoch J, Turenipseed WD. Limb-salvage angioplasty in vascular surgery practice. J Vasc Surg 2005; 41: 988-93.
Peripheral arterial angioplasty should be considered as an alternative to primary amputation in selected patients with Critical Limb Ischemia (CLI) who are poor candidates for traditional surgical bypass. Infrainguinal lower extremity bypass surgery for limb salvage is the gold standard treatment for ischemic nonhealing ulcers, gangrenous digits, or rest pain The comparative limb-salvage rates with Percuraneous Transluminal Angioplasty (PTA) and bypass surgery in the treatment of limb-threatening ischemia are 78% vs. 81%, respectively, at 2 years.
6 Bypasses Quality Indicator
 Type: RCT
Jivegard L, Drott C, Gelin J, Groth O, Hensater M, Jensen N, Johansson G, Konrad P, Lindberg B, Lindhagen A, Lundqvist B, Oden A, Smith L, Stenberg B, Thornell E, Wingren U, Ortenwall P. Effects of Three Months of Low Molecular Weight Heparin (dalteparin) Treatment After Bypass Surgery for Lower Limb Ischemia – A Randomised Placebo-controlled Double Blind Multicentre Trial. Eur J Vas Endovasc Surg 2005; 29: 190-198
This RCT evaluated the primary graft patency at 3 and 12 months after Peripheral Arterial Bypass Graft (PABG) surgery in patients receiving 3 months of treatment with subcutaneous injection of dalterparin. There is no difference in graft patency at 3 or 12 months between patients receiving 5000 IU of dalterparin daily for 3 months after bypass surgery versus those receiving placebo injections, so routine long-term Low Molecular Weight Heparins (LMWH) treatment after peripheral arterial bypass graft surgery for lower limb ischemia is not justified.
7 Bypasses Quality Indicator
 Type: Longitudinal study (1 group)
Feiring AJ, Wesolowski, Lade S. Primary Stent-Supported Angioplasty for Treatment of Below-Knee Critical Limb Ischemia and Severe Claudication. Journal of the American College of Cardiology 2004; 44(12): 2307-14.
Below-Knee Stent-Supported Angioplasty (BKSSA) for Critical Limb Ischemia (CLI) and Lifestyle-Limiting Claudication (LLC) improves ankle brachial indexes comparable to tibial bypass, heals amputations, relieves rest pain, and improves ambulation. In patient with CLI, the mean ABI increased from 0.32 ± 0.13 to 0.9 ± 0.14, (p≤0.0001). Those with claudication improved from 0.65 ± 0.09 to 0.95 ± 0.12, (p≤0.0001). Because BKSSA is associated with minimum major adverse events, it may be an alternative therapy for patients with CLI and LLC.
8 Bypasses Quality Indicator
 Type: Retrospective Analysis
Murphy TP, Ariaratnam NS, Carney WI, Marcaccio EJ, Slalby JM, Soares GM, Kim HM. Aortoiliac Insufficiency: Long-term Experience with Stent Placement for Treatment. Radiology 2004; 231(1): 243-249.
Findings from long-term experience with aortoiliac stent placement for treatment of chronic lower-extremity ischemia confirmed the procedure to be a durable, low-risk revascularization option. For patients with arterial stenosis, there was a significant mean reduction in pressure gradient, of 13 mm Hg (P < 0.001).


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