VASCULAR

ULCERS
PREPARED BY
NOOR SHEIKH
BSPT/t-DPT/MSNPT
“PERIPHERAL VASCULAR DISEASE” is a term
commonly used in reference to an ARTERIAL PROBLEM,
even though it includes diseases and conditions of the
VENOUS and LYMPHATIC SYSTEMS as well as the
arterial system

“Patients with leg ulcers may present with a combination of

arterial, venous, and lymphatic disease”
Leg and foot ulcers may have several different etiologies,
including arterial, venous, and lymphatic disease along with
trauma, infections, inflammatory diseases, and malignancy
VENOUS
INSUFFICIENCY
VENOUS INSUFFICIENCY
•Inadequate drainage of venous blood from a body part
usually resulting in
◦ Edema
◦ Skin Abnormalities
◦ Ulceration
•Chronic Venous Disease/Insufficiency (CVI) occurs over
the period of time
•Most common cause of leg ulcers (95%)
•Incidence is much higher than those of arterial ulcers
VENOUS INSUFFICIENCY
Venous ulcers were formerly known as “VENOUS STASIS”
ulcers because their development was thought to be caused
by blood pooled in the veins
More recent literature indicates that “VENOUS
HYPERTENSION” rather than venous stasis is both the
cause of these ulcers
 That’s the reason why they don’t heal
Contribution of skin breakdown made by dysfunction of
circulating WBCs, endothelial cell dysfunction, fibrin
deposition, edema and lymphatic congestion
VENOUS ANATOMY AND
PHYSIOLOGY
Origin & Formation:
◦ The venous system begins at the post-capillary level with
venules
◦ Venules coalesce to form small veins, which then merge to
create larger veins
◦ This coalescence progresses from the periphery towards a more
central location
 VENOUS ANATOMY AND
PHYSIOLOGY
Anatomic Variability:
◦ Similarities with arterial system but greater anatomic variability
◦ Leg veins with tibial and peroneal arteries often have cross-linking
branches, creating a retia appearance
Popliteal Vein:
◦ Ascending branches along tibial and peroneal arteries converge to
form popliteal vein.
◦ First vein of significant size in lower leg
 VENOUS ANATOMY AND
PHYSIOLOGY
Continuation to Femoral Vein:
◦ Popliteal vein becomes femoral vein.
◦ Femoral vein, despite being deep, is sometimes confusingly called
superficial femoral vein.
Common Femoral Vein:
◦ Superficial femoral vein joins deep femoral vein to form common
femoral vein.
◦ Deep femoral vein serves as deep drainage system for thigh
DUAL VENOUS SYSTEM
Dual venous system refers to presence of both superficial and
deep veins in body
There are superficial veins closer to the skin's surface and deep
veins situated within the muscle tissue
These two systems run parallel but serve different functions
Superficial veins are often visible and may be involved in
conditions like varicose veins, while the deep veins play a crucial
role in venous return and are part of the deep venous system
The two systems are interconnected through perforator veins. This
dual system helps maintain effective blood circulation and
drainage in the body
Unidirectional valves are present in the deep and superficial
venous systems and in the perforator veins
These valves are located just before bifurcation points
Greater Saphenous Vein contains approximately 6-8 valves
Loss of valve function at various levels results in varying
degrees of venous insufficiency
PATHOPHYSIOLOGY
•Symptomatic and asymptomatic thrombi can lead to long-term
complications
•Complications arise from scarring of the intima (inner layer of
blood vessels) & development of valvular incompetence
•Incompetent valves result in backward blood flow into distal veins
during diastole
•Loss of function in perforator valves contributes to high
intracompartmental venous pressure, reaching up to 200 mm Hg
during muscle contraction
Cont….
•Elevated pressure leads to distention of saphenous system,
particularly when perforator valves fail to prevent backward blood
flow
•Process creates a cascade effect, causing dilation of the greater
saphenous vein and worsening of compromised valve function.
•The weight of the blood column increases pressure inside
capillaries, contributing to further complications and challenges in
blood circulation
Disease states that cause loss of valve function include:
• Congenital Valve Absence
• Deep Vein Thrombosis
• Ectasia
• Phlebitis
• Valve Atresia
• Venous Engorgement
• Venous Hypertension
CONTRIBUTING FACTORS
1. Aging
2. Lack of exercise
3. Obesity
4. Pregnancy
5. Long hours of standing or sitting
6. Hereditary
7. History of vigorous activity in presence of other factors
 CLINICAL PRESENTATION
Chronic skin and subcutaneous lesions, Fibrosis of dermis
Complaints of itching, fatigue, aching, heaviness in involved
limbs
Swelling of uni/bilateral LE relieved in early stages by
elevation
 in skin temperature of lower leg
Can occur at any place but mostly on medial malleolus (Supra–
Malleolar Areas) & Pretibial Area
Not significantly painful, usually complaints of minor dull leg
pain
CLINICAL PRESENTATION
Skin changes includes
 Hemosiderin Staining – iron deposition
 Lipodermatosclerosis – changes in the skin and
subcutaneous tissue (fat layer) of the lower extremities,
particularly lower legs
 Associated with CVI and characterized by
• Inflammation  Fibrosis (formation of scar
tissue)
• Thickening of skin and underlying tissues
CLINICAL PRESENTATION
Granulation tissue is present in wound bed
Tissue is wet typically from large amount of draining
exhudate
Signs and symptoms of lymphadema may be present
History
Comorbidities like DM, HTN, CHF, DVT.
Long latency period all join hands
Suspicion in older patients as incidence increases with age
History of lingering swelling, slow healing, repeated
infections, and frequent recurrence of skin breakdown
Once ulceration occurs venous wounds can occur for years
Subsequent development of lymphadema
TESTS AND MEASUREMENTS
  Skin temperature
Edema decreases with elevation
Pitting edema may occur in peri wound area, foot and ankle
Advanced edema and lymphadema are usually unaffected
by elevation and requires compression
Strong distal pulses and normal ABI
INTERVENTION
The most important therapeutic measure is
COMPRESSION THERAPY
Excessive edema can delay wound healing by slowing
perfusion of tissues and facilitating the growth of bacteria
Along with compression and appropriate wound care
treatment will include
◦ Exercise to increase mobility
◦ Positioning to support and enhance venous blood flow
◦ Compression bandaging and garments, gait
INTERVENTION
Gait Training
Manual Lymphatic Drainage
ROM Exercises
Vascular Surgery
Avoid Whirlpool
VENOUS ULCER
ARTERIAL
INSUFFICIENCY
8-10% of patients with leg & foot ulcers have pure arterial
insufficiency
Principal etiology of leg ulcers is chronic venous disease, whereas
foot ulcers are much more commonly caused by arterial disease
Assess signs & symptoms of lower extremity arterial disease and
ulcers
 ARTERIAL SYSTEM
•Lower-extremity arterial perfusion begins with effective cardiac
function
•Blood exits the left ventricle and travels through the descending thoracic
aorta
•Intercostal arteries, originating from descending thoracic aorta, are
initial crucial collateral vessels for leg perfusion
◦ In cases of distal aortic occlusive disease, intercostal arteries play a
vital role as primary collaterals
•As aorta enters abd. cavity, its diameter  particularly after each major
arterial branch
•Most significant reduction in size occurs distal to renal arteries
 ARTERIAL SYSTEM
•At umbilical level, abd. aorta bifurcates into common iliac arteries,
branching into internal and external iliac arteries.
◦ Internal iliac arteries perfuse lower sigmoid colon and rectum
◦ External iliac artery transforms into common femoral artery at
inguinal ligament level
•Palpating the femoral artery at this level allows assessment of the
quality of the pulse wave
 FEMORAL
ARTERY
Common FEMORAL ARTERY divides
into TWO
1. DEEP FEMORAL ARTERY is a
crucial collateral pathway for lower
leg perfusion
◦ Its muscular perforators play a
significant role in restoring blood
flow to the popliteal artery in cases of
superficial femoral artery occlusions.
2. SUPERFICIAL FEMORAL
ARTERY transforms into the
popliteal artery after passing
◦ (Most Commonly OCCLUDED –
significant Ischemia )
ARTERIAL ULCER
Tissue breakdown in ulcers can be caused by various factors,
including thermal extremes, chemicals, or localized clots or
emboli, resulting in IMPAIRED ARTERIAL FLOW and
decreased cellular nutrition
Compromised or inadequate arterial blood flow  leading
to ischemia and difficulty in wound healing
Diminished arterial flow causes tissue hypoxia in arterial
insufficiency, potentially leading to gangrene or tissue necrosis
ARTERIAL INSUFFICIENCY
•Lack of adequate blood flow to a region or regions of the body
•Disruption of arterial blood flow to the extremities is PVD
(Peripheral vascular disease)
•Leading factors are
◦ Smoking
◦ Cardiac Disease
◦ Diabetes
◦ HTN
◦ Renal Disease
◦ Elevated Cholesterol & Triglycerides
ARTERIAL INSUFFICIENCY

Arteriosclerosis: thickening, hardening, and loss of elasticity of

arterial walls

Atherosclerosis: damage to the endothelial lining of vessels and

formation of lipids plaques

Arteriosclerosis Obliterans: peripheral manifestation of

atherosclerosis characterized by intermittent claudication, rest
pain and trophic changes
ARTERIAL INSUFFICIENCY

Thrmobo-Angitis Obliterans (Buerger’s Disease):

inflammation leading to arterial occlusion and tissue ischemia
especially in young men who smoke

RAYNAUD’S DISEASE: functional vaso-motor disease of small

arteries and arterioles not likely to cause ischemic necrosis
Ulceration: Peripheral sign of long standing disease
Ulceration chance is less but often leads to loss of limb and death
CLINICAL PRESENTATION

LE – Lateral Malleolus and Dosrum of foot

Atherosclerotic Occlusion is always present
 Majority – Diabetic Patients
Trophic changes are present that include abnormal nail
growth, decreased leg and foot hair, dry skin
Skin is cool upon palpation
CLINICAL PRESENTATION
Intermittent claudication and pain in limbs
Wound base is necrotic and pale lacking granulation tissue
Skin around the wound is black
Decreased pulses, pallor on elevation, rubor when dependent
Color changes of fingers and toes
Pain on elevation
SUBJECTIVE HISTORY
Painful cramping or aching of lower extremity during
walking is the most common complaint
◦ Is due to ISCHEMIA when exercising muscles are not
receiving blood perfusion
Rest pain that develops at night, awakens the patient or
required analgesic for relief is considered more severe
ABCDES IN DIAGNOSIS
A1C: Hgb A1C refers to personal or family history of diabetes
or arterial disease
Blood Pressure: Find out if it is elevated and if they are on
medications
Cholesterol: Elevated cholesterol is a risk factor and the use of
statin cholesterol lowering agents may reduce this risk
Diet and Obesity: Increased weight especially a body mass
index above 25 indicates an increased risk for heart and peripheral
vascular disease as well as diabetes.
Exercise
Smoking
TEST AND MEASUREMENTS
o Ankle-Brachial Index (ABI) test designed to examine vascular
system
o Capillary Refill
o Dopplers
CAPILLARY REFILL
Purpose Indicator of superficial blood flow
Method Observe color of patient’s skin in the area of interest
Apply pressure with enough force to blanch the patient’s skin
Interpretation <3 seconds=Normal capillary refill time
>3 to 5 seconds=Surface tissue perfusion is impaired
Advantages Quick, noninvasive, painless, Reliable and valid
assessment
Limitations May be affected by tissue temperature and patient
age
ARTERIAL ULCER