Dr Jason Toniolo

Arterial ulceration

Arterial ulcers form when not enough blood is delivered to the foot to heal a wound.

They can be painful and last for months without improving.

What causes the ulcers?

There may be some trauma to the foot, such as stubbing a toe against a table or wearing improperly fitted shoes. Usually, the wound would heal within a few weeks; however, if the arterial supply to the toes is damaged, the wound may fail to heal, or even worse, it may begin to develop a dark grey, purple or blackish discolouration (this indicates the development of gangrene or dead tissue).

To conceptualise how this happens, the foot’s soft tissue needs a certain amount of oxygen to keep the cells alive. To heal a wound, there is a much higher demand for oxygen to initiate the repair process. Whilst there may be enough blood (oxygen) to keep the already healthy skin, there may not be enough to heal the wound.

Vascular surgeons are responsible for assessing the blood supply to the foot and performing surgery to improve the blood supply when required. Their assessment involves examining the pulses in the foot, behind the knee or groin. Pulses can be challenging to feel if you are not trained in where to examine

Where do arterial ulcers develop?

The usual locations where they are found are over bony prominences. This is because the prominent bits of bone under the skin are more likely to rub or be injured when walking. The skin over the bone is generally fragile, and the amount of trauma to the skin is exaggerated when bone is underneath it.

Different parts of the foot derive oxygen from different vessels

treatment options

Treatment of arterial ulcers

When the presence of blocked arteries as a cause for an ulcer on the foot has been confirmed, the management is to restore the blood supply.

This is done by isolating which artery is blocked and how long the blockage is, using imaging to plan for intervention.

Surgery on blood vessels

Minimally invasive (endovascular) keyhole surgery, where wires, balloons and stents open a channel for blood to flow. Depending on what artery is blocked and how severe it is, sometimes a balloon alone is adequate; other times, a stent is required to hold the artery open and prevent it from re-narrowing.

Open surgical reconstruction involves opening up an artery and removing plaque (endarterectomy) or performing a bypass (attaching either vein or fabric above and below the blocked vessel so that the blood can bypass the blocked vessel and be delivered to the foot.

Offloading

Pressure should be taken off the wound until it heals, which involves wearing special shoes or boots that carry the weight off of the portion of the foot that has the wound. It is essential for diabetic patients, as they often don’t feel pain in their feet due to diabetic-related nerve damage (diabetic neuropathy)

Wound care

The goal of wound care is to remove exudate from the open wound, remove ‘slough’ (the medical term for the green film that forms over open flesh, which represents the battleground between bugs in the environment and the body’s immune cells) and keep the wound bed moist enough to encourage healing, but not so moist such that the surrounding skin gets ‘macerated’ (like when you sit in a bath for too long and the pulp of your fingers turn white)

Manage infection

Sometimes, there is an infection associated with the ulcer. This is treated with targeted antibiotics, and swabs are taken to identify which bugs are causing the infection.

Dr Jason Toniolo

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