Mixed Arterial and Venous

Recommendations

Identify and Treat the Cause
1 Assess all patients with leg ulcers for venous and arterial disease. Level of Evidence
Not Assessed
2 Take a careful history (venous/ arterial characteristics, other diagnoses, infection, medication, coexisting diseases, factors that may impair wound healing) Level of Evidence
Not Assessed
3 Perform a bilateral lower leg physical assessment including an ankle-brachial pressure index (ABPI). Level of Evidence
Not Assessed
4 Diagnose mixed venous/arterial ulcer in patients with venous disease and ABI 0.7–0.9. Level of Evidence
Not Assessed
5 Diagnose mixed arterial/venous ulcer in patients with venous disease and ABI <0.7. Level of Evidence
Not Assessed
6 Refer for revascularization if ABI<0.6, and refer urgently if ABI<0.5. Level of Evidence
Not Assessed
7 Do not implement high-compression bandaging if arterial disease is present (ABI<0.9). Level of Evidence
Not Assessed
8 Modify compression bandaging to treat the venous component if ABI >0.6. Level of Evidence
Not Assessed
9 Develop an individual treatment plan for patients with mixed ulcers, addressing the arterial and venous components appropriately. Level of Evidence
Not Assessed
10 For nonhealable or maintenance wounds, provide support, pain control and modified local care (conservative debridement, bacterial and moisture reduction) Level of Evidence
Not Assessed


Address patient-centered Concerns
11 Implement effective patient education and lifestyle changes to prevent ulcer recurrence and reduce the risk of myocardial infarction and stroke. Level of Evidence
Not Assessed
12 Educate patients about the need for lifelong compression hose and reinforce adherence frequently. Level of Evidence
Not Assessed
13 Communicate (patients, family, caregivers) to establish a social support system with realistic expectations for healing and to prevent leg ulcer recurrences. Level of Evidence
Not Assessed
14 Assess / Control pain and optimize activities of daily living Level of Evidence
Not Assessed


Provide Local Wound Care
15 Assess and document the wound at regular intervals. Level of Evidence
Not Assessed
16 Optimize local wound care: debridement, inflammation / infection control, and moisture balance. Consider biopsy of appropriate active (including biologicals) & adjunctive therapies if the wound is not healing at the expected rate. Level of Evidence
Not Assessed


Provide Organizational Support
17 Consult appropriate disciplines to maximize healing (e.g. mobility and nutrition). Level of Evidence
Not Assessed


Background

Mixed arterial and venous insufficiency is seen in <10% of leg ulcers. They often have their etiology in chronic venous insufficiency, and their ability to heal is affected by the severity of the arterial insufficiency. Arterial circulation that is adequate to maintain the viability of intact skin may be unable to support the increased metabolic demands of healing after even mild trauma, leading to ulcer formation. With increasing patient age and ulcer duration, the potential for mixed vascular ulcers increases.

Patients may present with symptoms that suggest both arterial and venous disease, such as claudication pain accompanying a venous leg ulcer The location of the ulcer may be outside the common area for a venous ulcer or may be deeper. Leg ulcers are associated with numerous patient-centred concerns, including increased stress; pain; and difficulty coping. Decreased mobility, sleep disruption and limited social interaction decrease patient quality of life.

Accurate diagnosis with evaluation of both arterial and venous systems is critical. Mixed venous/arterial ulcers are predominantly venous and generally have an ankle-brachial index (ABI) of 0.6-0.8, whereas mixed arterial/venous ulcers are predominantly arterial, and they have an ABI of <0.6. [NB: NEED ABI STANDARD FOR PRESENCE OF ARTERIAL DISEASE]

Mixed ulcers are difficult to manage. It is important to review the medical and surgical management options to determine if revascularization, vein surgery and compression therapy are appropriate. A combination of treatment approaches may be necessary:
♦ Surgical treatment: Revascularization is indicated if the ABI<0.6 and an urgent vascular referral is indicated with an ABI of <0.5. Revascularization is the initial intervention. Surgical treatment of venous ulcers is associated with <10% recurrence rate. It may be possible to treat both components surgically in one procedure, by using the incompetent vein as an arterial conduit.
♦ Compression: The most effective treatment for venous ulcers, high-compression bandaging, is contraindicated in the presence of any arterial insufficiency, and modified compression therapy is contraindicated in the presence of at least moderate arterial disease (<0.6). High-compression bandaging for the venous component of the ulcer may be instituted after the arterial circulation has been restored.
♦ Local wound care: Wound assessment establishes a baseline for developing an individualized wound care plan. Local wound care includes debridement; cleansing; identification and treatment of critical colonization and infection; attention to moisture balance; and appropriate dressings. Arterial ulcers tend to be dry, and the wound should be kept dry After revascularization, normal wound care approaches generally result in healing of arterial ulcers. Infection is uncommon until perfusion is restored. If infection is present however it should be treated promptly as it can progress quickly. If infection develops after reperfusion, antibiotic therapy and surgical debridement may be necessary. Autolytic debridement is most commonly used for venous ulcers. Dressings should be selected on an individual basis based on their characteristics and desired action and on patient comfort and cost effectiveness.
♦ Exercise: Exercise therapy may improve healing.
♦ Medical therapy: Pentoxyfilline and micronized purified flavonoid fraction (MPFF) are effective for healing venous ulcers. Stanozolol has been shown significantly to reduce the area affected by chronic lipodermatosclerosis.
♦ Advanced therapies: Topical negative pressure, hyperbaric oxygen, electrical stimulation, therapeutic ultrasound, biologicals and skin substitutes may stimulate healing at the edge of nonhealing wounds (edge effect).
♦ Patient factors: Identified factors that may affect healing, such as poor nutrition and sedentary lifestyle, can be addressed through an exercise prescription and management of nutritional deficiencies.
♦ Adjunctive therapies: Physical therapy may improve restricted ankle mobility. Both therapeutic ultrasound and electrical stimulation may accelerate ulcer healing.
Lifelong use of support hose is usually necessary to prevent recurrence, and lifestyle changes are also important to address vascular disease risk factors, including smoking, hypertension, dyslipidemia, sedentary lifestyle and obesity. Lifestyle change can reduce the risk of ulcer recurrence and of cardiovascular events, such as myocardial infarction and stroke.
Effective communication and patient, family and caregiver education (especially incorporating self-management components) are critical in obtaining adherence to therapeutic and preventive strategies and achieving optimal long-term outcomes.

References

Essential Publications
1 Mixed Arterial and Venous Quality Indicator
 Type: RCT
Romanelli M, Dini V, Bertone M, Barbanera S and Brilli C. OASIS wound matrix versus Hyaloskin in the treatment of difficult-to-heal wounds of mixed arterial/venous aetiology. Int Wound J 2007; 4:3-7
This study evaluated the effects of OASIS and Hyaloskin in their ability to achieve complete wound healing of mixed arterial/venous ulcers. Complete wound closure was achieved in 82.6% of OASIS-treated ulcers compared with 46.2% of Hyaloskin-treated ulcers (P<0.001). Treatment with OASIS also resulted in significantly less pain than treatment with Hyaloskin (P<0.05). Overall, OASIS was superior to Hyaloskin for the treatment of mixed arterial/venous ulcers.
2 Mixed Arterial and Venous Quality Indicator
 Type: RCT
Vijayaraghavan KS, Ayyappan MK, Ganesh S, Bhattacharya K. Chronic Nonhealing Ulcer of the Lower Limb With Mixed Arterio-Venous Pathology. The International Journal of Lower Extremity Wounds 2004; 3(1): 47-48.
This study shows that when there is coexistent mixed pathodology, it is mandatory to evaluate arterial flow and, when there is evidence of moderate to significant ischemic disease, treat as deemed fit.
3 Mixed Arterial and Venous Quality Indicator
 Type: Prospective Correlation study
Ghauri ASK, Nyamekye K, Grabs AJ, Farndon JR, Poskitt KR. The Diagnosis and Management of Mixed Arterial/Venous Leg Ulcers in Community-based Clinics. Eur J Vasc Endovasc Surg 1998; 16: 350-355.
In this study, limbs with mixed disease were treated according to the resting ankle-brachial pressure index. Ulcers with venous and a severe arterial component responded slowly despite early aggressive revasculisation. Overall, this study indicated that supervised modified compression bandaging in ulcerated limbs with mixed venous ad moderate arterial disease is safe and effective.


Enablers for practice

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