Venous and arterial leg ulcers
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Consultation en clinique ou en téléconsultation, partout au Québec.
Differential diagnosis - comparative features
| Features | Venous ulcer | Arterial ulcer | Mixed ulcer |
|---|---|---|---|
| Location | Inner malleolar region («gaiter») ++ + inner and outer malleolus + lower third of leg | Toes + heels + pressure areas + between toes + distal and acromial areas | Variable - may be atypical |
| Wound appearance | Irregular borders + red + pinkish + exudative background + hyperpigmented border (ochre dermatitis) + periulcer induration | Clean edges + «perforating» + pale or blackish background + necrotic + little or no exudate + surrounded by thin skin + cold | Mixed aspects |
| Pain | Moderate + relieved by elevation and walking + aggravated in declive position (legs hanging) | Intense + throbbing + aggravated by elevation + relieved in declive position (hanging legs = analgesic position) + claudication | Varies according to dominant component |
| Peripheral pulses | Present (sometimes masked by edema) + normal IPS ≥ 0.9 | Absent or reduced + IPS < 0.8 | Reduced + IPS 0.5-0.8 |
| Peri-ulcer skin | Lipodermatosclerosis + hyperpigmentation (ochre dermatitis = hemosiderin deposits) + visible varicose veins + corona phlebectatica + venous eczema | Cold + smooth + hairless + white or mottled skin + cyanosis of toes + thick nails | Mixed |
| Contributing factors | Previous DVT + varicose veins + obesity + sedentary lifestyle + standing job | Smoking + hypertension + diabetes + dyslipidemia + history of coronary heart disease or stroke (atherosclerosis) | Combining the two |
| IPS (systolic pressure index) | ≥ 0.9 (normal) | < 0.6 (severe ischemia) or 0.6-0.8 (moderate ischemia) | 0,5-0,8 |
Systolic Pressure Index (SPI) - essential measurement
- Technology: ratio of systolic arterial pressure measured at the ankle (by Doppler) to systolic arterial pressure at the arm → IPS = Ankle BP / Arm BP
- Interpretation : IPS ≥ 0.9 = normal + IPS 0.7-0.9 = mild ischemia + IPS 0.4-0.7 = moderate ischemia + IPS < 0,4 = ischémie sévère (douleur de repos + risque d'amputation) + IPS > 1.3 = mediacalcosis (incompressible arteries - diabetes + CKD + overestimation of pressure) → use digital pressure or TcPO₂ in this case
- Compression thresholds : IPS ≥ 0.8 → high pressure compression allowed (40 mmHg) + IPS 0.6-0.8 → light compression possible (20-30 mmHg) under supervision + IPS < 0.6 → compression CONTRAINDICATED → urgent vascular referral
Treatment of venous ulcers
- Venous compression (mainstay of treatment) : multi-layer bandage (4 layers - Profore® + or equivalent) or short elasticity bandage - ankle pressure 35-45 mmHg + reduction in venous hypertension + improvement in venous return + healing rate at 12 weeks: 65-75 % under compression vs 20-25 % without compression + after healing: class II-III compression stockings for life to prevent recurrences
- Detersion and wound cleansing : mechanical debridement (curette + scalpel) + or enzymatic + or autolytic (hydrocolloid dressings) → remove necrotic tissue + biofilm + fibrin → promote budding
- Dressings : choose according to the level of exudate + hydrocolloid dressings (moderate exudate) + silver dressings (if superinfection) + foams (abundant exudate) + interfaces (fragile wounds) + never occlude a superinfected wound → change 1-3 × / week according to exudate
- Venous surgery : treatment of underlying varicose veins (stripping + laser + sclerotherapy + EVLA) → reduces the risk of recurrence → to be considered after healing + or in parallel if varicose veins are severe
- Skin grafting : split-thickness skin graft + or keratinocyte graft + or skin substitutes → for large + chronic + non-healing ulcers despite optimal compression × 12 weeks
- Pentoxifylline (Trental®) : 400 mg × 3/d per os → improves microcirculation + reduces vascular inflammation + modest efficacy on healing in addition to compression
Treatment of arterial ulcers
- Revascularization (etiological treatment) : percutaneous transluminal angioplasty (PTA) + or bypass surgery (prosthetic + or venous) + depending on location and extent of arterial lesions → objective: restore sufficient perfusion to allow healing
- Medical treatment of atherosclerosis : statins + ACE inhibitors or ARB II + antiaggregants (aspirin + or clopidogrel) + strict blood pressure control + smoking cessation (essential) + diabetes control + progressive therapeutic walking (if GPI ≥ 0.5)
- Local care - arterial wound : NON-occlusive dressings + dry maintenance of stable dry necrosis (protection) → do not debride dry necrosis without prior revascularization → moisten dressings + avoid maceration + delicate care
- Compression CONTRAINDICATED if IPS < 0.6 : worsens ischemia + risk of gangrene + amputation
- Amputation: if irreversible ischemia + extensive dry or wet gangrene + osteoarticular infection (osteomyelitis) + or if revascularization impossible
Consult a doctor or angiologist promptly if a leg ulcer fails to heal despite treatment + or if signs of severe ischemia appear (resting pain + cold, bluish toes + darkening of the skin) + or if deep wound infection (cellulitis + osteomyelitis + fever) is suspected. Consult the emergency room immediately if wet gangrene + sepsis + or severe rest pain develops. For Doppler IPS evaluation and chronic wound management, Clinique Omicron offers medical consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (SPNs) assess leg ulcers and measure SPI by Doppler prior to compression, distinguish venous from arterial ulcers, initiate multilayer compression for venous ulcers (SPI ≥ 0,8), prescribe appropriate wound care according to the nature of the ulcer, refer to vascular surgery for revascularization if SPI < 0.6, and coordinate multidisciplinary follow-up (wound nurse + podiatrist + vascular surgeon). Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of a physician, angiologist or vascular surgeon. Venous compression is formally contraindicated if the SPI is less than 0.6 - its application on an arterial ulcer may lead to aggravated ischemia and amputation. Doppler measurement of SPI should always be performed before compression.
Omicron Clinic
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