Arterial leg ulcers

ICD-11

BD52, EF60

Synonyms

None.

Epidemiology

Prevalence of all leg ulcers: 1-2% in the general population, 4–5% of individuals older than 80 years. PAOD: the cause of 5-10% of leg ulcers, mixed CVI (Chronic Venous Insufficiency) PAOD in 20%. Ulcus hypertonicum Martorell: 5%.

Definition

A chronic ulcer due to peripheral arterial occlusive disease (PAOD).

Aetiology & Pathogenesis

Chronic limb ischemia due to arterosclerosis of small, middle-sized and large arteries. Frequent trigger is a minor trauma. Martorell’s ulcer combines PAOD with hypertensive arteriopathy and skin infarction in patients with essential arterial hypertension.

Signs & Symptoms

Severe local pain.

Clinical description of ulcer.

Localisation

Lateral side of the lower leg, proximal from (or including) the lateral malleolus or pretibial.

Classification

Fontaine stage IV and Rutherford stages III and IV define ulceration with distal necrosis.

Laboratory & other workups

None.

Dermatopathology

Biopsies from the edge of the wound should be considered if an ulcer does not respond or responds inadequately to therapy or has an atypical appearance, in order to exclude malignancy and to differentiate squamous cell carcinoma from pseudocarcinomatous hyperplasia.

Course

Chronic, progressive.

Critical ischemia: poor prognosis without re-vascularization.

Complications

In addition to loss of function, cellulitis (erysipelas) with an ulcer as the entry site and necrotizing fasciitis, amputation and increased mortality.

Diagnosis

Clinical examination: Absent foot pulses, cold extremities, severe wound pain, claudicatio intermittens, rest pain, distal necrosis.

Apparative examination: Systolic ankle and toe pressure, ankle brachial index (ABI): 0.9 or less, transcutaneaous oxygen pressure (tcPO2), duplex sonography, angiography.

Differential diagnosis

Other vascular diseases, haematological diseases, infections, traumatic/physical, autoimmune, tumor, metabolic/endocrine, iatrogenic, neoplasia.

Prevention & Therapy

Prevention: healthy lifestyle, muscle activities, smoking cessation, reduction of metabolic disorder-related factors (hyperlipedemia, diabetes).

Topical treatment: Appropriate phase-adjusted therapy of chronic wounds: Debridement (surgical, enzymatic), enhance granulation in moist milieu, encourage re-epithelialisation in non-occlusive, semi-moist milieu.

Medications improving arterial flow by infusion (PGE1, vasodilatators).

Angioplasty stents, bypass surgery.

Martorell’s ulcer: necrosectomy and split skin transplantation.

Special

5-10% of ulcers on lower leg are neuropathic (metabolic disorders [diabetes mellitus], alcoholism, leprosy, neurosyphilis, traumas in polyneuropathy).

5.2.2 Arterial leg ulcers