Arterial Ulcer : Frequently Asked Questions

A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years.

WHAT IS ARTERIAL ULCER (AU)?

Arterial insufficiency ulcers (also known as ischemic ulcers, or ischemic wounds) are mostly located on the lateral surface of the ankle or the distal digit. They are commonly caused by peripheral artery disease (PAD).

HOW DOES AU HAPPENS?

The ulcers are caused by lack of blood flow to the capillary beds of the lower extremities. Arterial insufficiency is caused by high blood pressure and narrowing of the arteries due to atherosclerosis. Atherosclerosis is due to deposits 

of circulating lipids at the sites of damaged vessel walls as a result of the effects of smoking and high blood pressure. These deposits partially occlude the artery, resulting in reduced blood flow to tissues. Also, in diabetic patient, there will be condition called angiopathy. When happened, it will cause abnormalities inside blood vessels and capillary due to injury to endothelial cells associated with neuropathy. This will lead to poor perfusion of tissues, especially wound base. When pressure is placed on the skin, the skin is damaged and is unable to be repaired due to the lack of blood perfusing the tissue. ​

WHERE DO AU USUALLY HAPPEN?

They are most common on distal ends of limbs. A special type of ischemic ulcer developing in duodenum after severe burns is called Curling's ulcer.

 WHAT IS HAPPENING IN EARLY PHASE OF AU?

Most often, an AU develops following a minor injury that is slow to heal due to the poor blood supply to the wound. In severe arterial disease, spontaneous cell death may cause skin breakdown without a precipitating injury. Alternatively, cholesterol deposits lining the blood vessel walls may break off and become lodged in smaller vessels downstream, causing a sudden and complete blockage in flow; this process is called embolic occlusion

WHAT ARE THE EARLY SIGNS AND SYMPTOMS OF AU?

• Cramping pains in the buttocks and back of the legs during exercise, relieved by rest (intermittent claudication); this is due to insufficient oxygen supply to meet the increased needs of exercising muscle.
• Often the limb will feel cool or cold to the touch, and the extremity will have little to no distinguishable pulse.​

• Burning leg or foot pain at rest, which is relieved by lowering the foot and made worse by elevating it. temporary relief from this pain is dangling the affected legs over the edge of bed, allowing gravity to aid blood flow to the ulcerous region.​
•  The skin and the nails on the extremity will also appear atrophic, with hair loss on the affected extremity, while also taking on a shiny, thin, dry, and taut appearance.
•  In addition, the base color of the extremity may turn red when dangled and pale when elevated. An additional sign of an AU is delayed capillary return in the affected extremity.

WHO ARE THE MOST COMMON TO GET AU?

Certain lifestyle factors and medical conditions have been associated with the development of AU. These include:

• Diabetes
• Smoking
• High blood fat and cholesterol
• High blood pressure
• Renal failure
• Obesity
• Rheumatoid arthritis
• Clotting and circulation disorders
• Other arterial disease, such as heart disease, cerebrovascular disease and peripheral vascular disease.

HOW DOES AU LOOK LIKE?

• Located on the lower legs and tops of the feet or toes
• A tendency to be painful, particularly at night
• A symmetrical shape with well-defined borders, often described as having a 'punched-out appearance'
• Minimal bleeding when touched or knocked
• Cool, pale or bluish surrounding skin that appears shiny
• Loss of leg hair
• Faint or absent ankle pulse​

HOW SIGNIFICANT IS AU?

Left untreated, AU can lead to serious complications, including infection, tissue necrosis, and in extreme cases amputation of the affected limb.

Foot of an 80-year old individual with type 2 diabetes and heart failure. The second toe has a large ischemic ulcer. The first toe has a small one.

"Should I be worried if I got AU?"

WHAT ARE TREATMENT MODALITIES FOR AU?

The primary goal of the treatment of AU is to increase circulation to the area, either surgically or medically :

(a) Surgical Options

Surgical options range from revascularization in order to restore normal blood flow to amputation and rehabilitation in patients who cannot be revascularized.

(a) Non-Surgical Options

• Modifying certain lifestyle and contributing factors can slow or stop the progression of the local ischemia. Eg: stop smoking, blood glucose control and dyslipidemia control
• Boots and pumps available to augment perfusion to the affected limb.

 "In an open non-healing wound of AU, patient can opt for skin graft / skin substitute"

CelltiSS

• A Collagen Induced Growth Factors (CIGF™️) solution that is formulated for topical administration on the wound surface. 
• To treat and manage major skin loss by preparing the wound bed for skin implantation. 
• Consists of various types of fibroblast- derived bioactive factors in the secretomes of the fibroblasts.
• Indicated for wound bed preparation in full thickness skin loss due to AU and other type of non-healing ulcer and burn.

​CelltiGraft™️

• Autologous Bilayered Tissue Engineered Human Skin (TEHS).
• constructed from patient’s own skin cells through a small biopsy in cGMP lab.
•  modification of the flagship product, MyDerm®.
• alternative to the conventional Split Skin Grafting (SSG) method.

​ALGraft.

• An allogeneic bi-layered Tissue Engineered Human Skin (TEHS) construct.
• Substitute for autologous TEHS patients with limited donor site.
• Indicated for full thickness skin loss due to AU and other type of non-healing ulcer and burn.

 TIPS FOR PATIENT WITH AU

The following precautions can help minimize the risk of developing AU in at-risk patients and to minimize complications in patients already exhibiting symptoms:

• Examine feet (especially between the toes) and legs daily for any unusual changes in color or the development of sores.
• Quit smoking. Smoking can harden or clog the arteries, leading to improper perfusion to the extremities.
• Manage blood pressure, cholesterol, triglyceride and glucose levels.
• Ensure that footwear is properly fitted to avoid points of rubbing or pressure. Avoid wearing constrictive socks.
• Avoid crossing legs while sitting.
• Avoid sitting or standing for extended periods.
• Avoid cold temperature.
• Protect legs and feet from injury and infection.
• Exercise as frequently as is comfortable.

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