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Fact File - Assessing mixed venous and arterial leg ulcers

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VOL: 102, ISSUE: 44, PAGE NO: 58

Caroline Dowsett, MSc, Bsc, DipN nurse consultant, tissue viability, Newham PCT, London

Mixed venous and arterial disease accounts for approximately 13-15% of all leg ulceration (Kippel and Dieppe, 1998; Bakeret al, 1991). These ulcers cause considerable pain and distress for patients and pose a difficult wound-management problem forhealth professionals. Many patients have significant oedema that needs to be controlled but also have some degree of arterialdisease where compression bandaging is contraindicated.

Aetiology

Venous hypertension occurs in limbs where the venous valves are damaged or where the calf-muscle pump is inactivated. Whena person is mobile dorsiflexion of the foot activates the calf-muscle pump which forces venous blood back to the heart but whenpatients become immobile the calf-muscle pump is inactivated. This leads to increased venous hypertension causing expansion ofthe capillaries in the lower limbs and blood cells to leak into the tissue resulting in oedema and then ulceration.

Atherosclerosis is the most common cause of insufficient arterial blood supply to the lower limb. It is caused by thedeposition of fatty material on the walls of blood vessels which form plagues leading to a narrowing of the lumen of theartery. It may also lead to thrombi, emboli and ischemia (Rose, 1991). Older people usually have some degree of atherosclerosisand the extent of resultant ischemia depends on the site of the occlusion and whether there is an effective collateralcirculation.

Assessment

Assessment is the key to effective management of mixed venous and arterial ulcers and should include the past medicalhistory as well as presenting signs and symptoms can help to differentiate between the degree of venous and arterial disease.Diagnosis can be complex, given that these patients present with characteristics of both diseases (Table 1).

It is important to remember that patients who originally present with venous ulceration may develop arterial disease,particularly as they get older (Simon et al, 1994).

All patients presenting with a new leg ulcer should have a full and detailed assessment, as should patients who have achange in their condition during treatment for ulceration (RCN, 1998). Box 1 lists the key components of the assessment.

Table 1. Characteristics of arterial and venous ulcers

 Arterial ulcerVenuous ulcer

Cause

Arterial disease

Chronic venous hypertension

Site (often an area of pressure)

Lower foot or toes

Gaiter area or medial malleolus

Oedema

Dependent oedema

Greater at end of day

Foot pulses

Absent or diminished

Present

Skin changes

Shiny, pale hairless, cold to touch

Warm to touch, brown pigmentation, eczema, ankle flare (visible capillaries around the ankle), varicose veins

Pain

Severe pain, on elevation of the limb and exercise. Intermittent claudication, rest pain

Heavy, aching feeling. Pain with infection and oedema

Appearance of the ulcer

Deep with necrotic base. Tendon or bone visible

Shallow and flat. May have granulation tissue present

Associated past medical history

Peripheral vascular disease, rheumatoid arthritis, diabetes, hypertension

Varicose veins, deep vein thrombosis, multiple pregnancies, family history, trauma to lower limbs

 

Box 1. Components of assessment

Past medical history

Current history

Mobility

Nutritional status

Pain

Quality-of-life related issues

Ankle circumference

Episodes of ulceration

Ulcer duration

Ulcer location

Wound bed type

Condition of surrounding skin

Measure ABPI

Vascular assessment

A Doppler assessment should be undertaken to determine the patient’s ABPI. It is important to remember that the diagnosisshould not be based solely on the results of the Doppler but on the combination of the patient’s history, presenting signs andsymptoms and the Doppler result.

The Doppler test determines the percentage of arterial blood supply into the limb and can indicate the level ofcompression that is appropriate for that patient. However, the ABPI reading may not always be reliable, particularly inpatients with diabetes or those with calcification of the arteries, who may have a falsely elevated reading.

The European Wound Management (2003) position document, Understanding Compression Therapy, proposes a diagnosis and treatment pathway to guide the practitioner in making adifferential diagnosis. This pathway breaks mixed arterial and venous ulcers into two categories:

  • Mixed arterial and venous ulcer where there is a moderate degree of arterial insufficiency with an ABPI of 0.5-0.8;
  • Mixed arterial and venous ulcer where there is severe arterial insufficiency with an ABPI of <0.5.

Further vascular investigation including a Duplex scan will be carried out to see the extent of arterial occlusion and theappropriateness and type of vascular surgery required. Angioplasty may be given to those who are unfit for bypass surgery.

Treatment

Reduced compression has been shown to be effective in the management of patients with mixed venous arterial ulcers with anABPI of between 0.5-0.8 (Simon et al, 1996; Moffatt et al, 1992; Stevens et al, 1992). This should be carried out inconsultation with a specialist nurse and the vascular team.

Reduced compression effectively applies 15-25mmHg compression (European Wound Management Association, 2003). This can beachieved by omitting a bandage layer in a multi-layer system or by using specific kits that are now available to give reducedcompression. The degree of patient tolerance should be closely monitored.

There is also evidence to support the use of short stretch bandages in mixed venous and arterial disease, particularlywhere patients experience pain at rest or at night, as these bandages apply low pressure to the limb when the patient isresting but higher pressure is exerted on movement (Butcher, 2002; Poore, 1998). For some patients intermittent pneumaticcompression therapy will be successful (Vowden, 2001).

Patients need to be monitored regularly for increased levels of pain or a reduction in ABPI. If the patient’s painincreases, the ulcer fails to respond or deteriorates, or the ABPI reduces, further investigations should be considered(Anderson and King, 2006).

Management of the wound bed

The wound bed in mixed arterial and venous ulcers is often sloughy, exudative and can become infected. The choice ofprimary dressing used to cover the wound will be determined by identifying the treatment objective, which may be debridement,moisture balance or infection control.

The skin surrounding the ulcer should be protected with a barrier film, cream or zinc paste bandage strips (Stevens,2004).

Conclusion

The management of patients with mixed venous/arterial leg ulcers is challenging. Many patients can be successfully managedwith reduced compression, however, the decision to undertake this treatment should be based on a detailed assessment, and inconsultation with the multidisciplinary team that must include a vascular consultant.

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