Management of Arterial Ulcers

Diagnosis and Assessment

Evaluate the entire lower extremity arterial circulation with detailed visualization of below-the-knee and pedal arteries to determine the extent of peripheral artery disease (PAD) 4, 5
Measure ankle systolic pressure and ankle-brachial index (ABI); an ABI <0.9 indicates PAD, while ABI 0.9-1.3, toe brachial index ≥0.75, or triphasic pedal Doppler arterial waveforms largely exclude PAD 4, 5
Consider urgent vascular imaging when toe pressure is <30 mmHg, transcutaneous oxygen pressure (TcPO₂) <25 mmHg, ankle pressure <50 mmHg, or ABI <0.5 4, 5
Differentiate neuroischemic ulcers (painful, absent pulses, irregular margins, commonly on toes, pale/cyanotic appearance) from neuropathic ulcers (painless, normal pulses, punched-out appearance, often on sole or metatarsal head) 6, 7

The primary treatment for arterial ulcers is revascularization to restore direct blood flow to at least one foot artery, preferably the artery supplying the anatomical region of the wound 4, 5
The goal of revascularization is to achieve minimum skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO₂ ≥25 mmHg 4, 5
Consider both endovascular techniques and bypass surgery based on morphological distribution of PAD, availability of autogenous vein, patient comorbidities, and local expertise 2, 4, 5, 8
For aorto-iliac disease, endovascular approach is the first choice, with surgery reserved for extensive obstructions or unsuccessful endovascular procedures 2, 3
For femoro-popliteal disease, select revascularization strategy according to lesion complexity; if bypass surgery is chosen, use the shortest possible bypass with saphenous veins 3
Avoid revascularization in patients where the risk-benefit ratio for success is unfavorable (severe frailty, short life expectancy, poor functional status, bed-bound, or large volume of tissue necrosis) 5, 8

Provide aggressive cardiovascular risk management including treatment of hypertension 2, control of glycemia in diabetic patients 2, prescription of statins 3, and low-dose aspirin or clopidogrel 2, 5, 8
Treat infection with appropriate antibiotics; in diabetic or immunocompromised patients, infections tend to be polymicrobial and may require systemic antibiotic therapy 6, 7
For deep-seated infections, obtain X-ray or MRA to diagnose osteomyelitis, which requires a longer course of antibiotics 3
Ensure aggressive offloading of mechanical tissue stress to allow wound healing 2, 3
Lower-limb exercise training is contraindicated until ulcers are healed 2, 3

Provide optimal wound care with appropriate dressings; while evidence for superiority of specific dressings is lacking, individualized treatments may include antimicrobial dressings, silver dressings, honey or iodine-based dressings, platelet-rich plasma, collagen, and negative pressure therapy 2, 3
Assess for venous etiology in mixed ulcers, which may require compression therapy after revascularization 3

Management by a vascular team including at least a vascular physician, vascular surgeon, and radiologist is recommended 1, 2, 3
After revascularization, patients should be treated by a multidisciplinary team as part of a comprehensive care plan 4, 5
For patients with signs of PAD and foot infection, emergency treatment is required as they are at particularly high risk for major limb amputation 4, 5
Regular surveillance should be performed during subsequent examinations, with thorough inspection of the feet to evaluate for early signs of skin breakdown or ulceration 6, 7

Diabetic microangiopathy should not be considered the cause of poor wound healing in patients with foot ulcers 4, 5
In patients with non-healing ulcers despite optimal management for 6 weeks, consider vascular imaging and revascularization regardless of bedside test results 4, 5