Ulcerations Due to Peripheral Vascular Disease

1. Ulcerations Due to Peripheral Vascular Disease Mark Finkelstein DPM Board-Certified, American Board of Podiatric Surgery Board-Certified, American Board of Podiatric Medicine

2. Comprehensive Assessment • Complete History and Physical- claudication?, Rest pain, night pain? History of smoking? • Lower extremity examination-always check between the toes • Wound assessment-infection,size,depth,exudate,base • Vascular assessment-Pulses, Non Invasive testing, Angiogram

3. Arterial Ulcer Characteristics • Located on bony prominences of the legs and feet • “Punched-out” appearance with well-defined borders • Shiny atrophic skin, no hair growth • Little/no edema or wound exudate • Yellow slough or black eschar in the wound bed with little granulation tissue • Feet are cool to touch and pedal pulses are often not palpable

4. Arterial Ulcer Characteristics

5. Assessment of Pedal Pulses

6. Vascular Assessment-Clinical Elevation Pallor Dependent Rubor

7. Treatment of Arterial Disease • Refer for vascular evaluation • Cardiovascular disease should be identified and managed • Recommend tobacco cessation • Increase regular exercise to improve symptoms of claudication

8. Treating The Arterial Wound • Do not debride dry, stable eschar until perfusion status is determined • For ulcers with insufficient flow, maintain dry, stable eschar

9. Treating the Arterial Wound • For ulcers with sufficient arterial flow, implement moist wound healing, enzymatic debridement and proper offloading • Treat infection promptly -consider Infectious Disease Consult

10. Vascular assessment • Noninvasive vascular testing

11. Vascular Assessment • Evaluate vascular status with angiogram

12. Vascular treatment • Endovascular- Techniques

13. Vascular treatment • Surgical Bypass-

14. Evaluate risk factors for atherosclerosis • Smoking, diabetes, hypertension, hypercholesterolemia, advanced age, obesity, family history • Review of labs to identify risk markers –elevated total cholesterol, triglycerides and reduced high density cholesterol

15. Multidisciplinary approach Medical therapy- beta blockers, statins, ACE inhibitors and antiplatelet therapy 2. Teach chronic disease management 3. Optimize nutrition 4. Tobacco cessation programs 5. Evaluate functional, cognitive and emotional state of the patient

16. Multidisciplinary approach • Increase regular exercise and physical activity to improve symptoms of claudication • Proper pain control of ulcerations

17. Arterial ulcers -Summary • Requires a multidisciplinary approach for proper management Wound Care Specialist-Podiatrist, Wound Nurse Vascular /Interventional Radiologist Vascular surgeon Primary Care Physician Dietitian Mental Health Provider Orthotist Physical Therapist Pain Management Specialist

18. Arterial ulcerations QUESTIONS THANK YOU