National best practice and evidence based guidelines for wound ...

3.4 Guidelines for management of arterial ulcers – Key Points (level of evidence)
Assessment
● All patients with lower extremity ulcers should be assessed by a person trained in leg ulcer
assessment (level 1).
● Patients presenting with rest pain or gangrene should be promptly referred to a vascular specialist
(level 1).
● An arterial ulcer is a component of a pool of diseases. It is paramount to evaluate the patient as
a whole, identifying and addressing the causes of tissue damage. This includes observation and
assessment of systemic diseases and medications, nutrition, tissue perfusion and oxygenation
(level 2).
● Patients presenting with risk factors for atherosclerosis (smoking, diabetes, hypertension,
hypercholesterolemia, advanced age, obesity, hypothyroidism) and who have ulcers, are more
likely to have arterial disease ulcers and should be carefully and broadly evaluated (level 1).
● In arterial ulcers, evaluate for contributing factors other than atherosclerosis that involve the
arterial system (microvascular vs. macrovascular) such as thromboangiitis, vasculitis, Raynauds,
pyoderma gangrenosum, thalassemia, or sickle cell disease (level 1).
Objectives
● Discuss the outcome of assessment with the patient. Identify and agree short and long term
treatment objectives.
● Refer as appropriate to members of the multi-disciplinary team for assessments and appropriate
interventions.
● Identify a time frame to review the objectives.
Treatment
● In the presence of an arterial ulceration, adjuvant therapies may improve healing of the ulcer
but do not correct the underlying vascular disease. They cannot replace revascularisation.
Revascularisation is not always successful and durable. Thus adjuvant therapy may improve the
outcome if combined with revascularisation (level 2).
● In general, removal of all necrotic or devitalised tissue by sharp, enzymatic, mechanical, biological,
or autolytic debridement leads to a more normal wound –healing process (level 2). In arterial
ulcers with dry gangrene or eschar, however, debridement should not be used until
arterial inflow has been established (level 3).
● Routine use of antibiotics is unnecessary unless there are signs of infection. (level 2)
● Wound healing potential is enhanced and infection potential is reduced in a wound environment
that is adequately oxygenated (level 1).
● Compression therapy may be beneficial in ulcers of mixed aetiology but should only be undertaken
with close supervision by an individual trained in management of patients with arterial leg ulcers.
(level 3).
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