In order to be effective in the challenging environment of chronic extremity ulcer management, clinicians must have a thorough understanding of arterial disease in its presentation and management. Venous wounds account for a majority of lower-extremity ulcerations in industrialized countries (approximately 80%-90%). Within that population, mixed disease presentation, or the presence of both venous and arterial insufficiency is estimated to occur in about 25% of those cases.1,2 This chapter provides a framework for evaluation and treatment of arterial ulceration.
Pathophysiology, Etiology of Arterial Insufficiency
Oxygen is essential in the air we breathe and in the most basic cellular processes: It sustains life on innumerable physiological levels. Ischemia, or the lack of oxygen via blood supply to the body's tissues, is the fundamental problem underlying arterial insufficiency (AI). Common nomenclature exists, and the terms arterial insufficiency, arterial disease, peripheral vascular disease (PVD), and peripheral arterial disease (PAD) may be used interchangeably. Clearly, "PVD" is a less specific term, as the reference may be venous or arterial, and "AI" or "PAD" is preferred in medical communication.
Ischemia may affect any tissue of the body; it may be classified as cerebral, visceral, or, as in the focus of this chapter, peripheral. Cerebral ischemia is seen most commonly with a cerebrovascular accident (CVA), or thrombolytic stroke, whereas visceral ischemia may affect any organ system from gastrointestinal, as seen with ischemic bowel, to cardiac, with myocardial infarction. Peripheral ischemia, or PAD, manifests as claudication and extremity ulceration.
PAD is a broad term used to describe a number of disorders that ultimately lead to reduction of blood flow to the extremities. Symptoms occur when the arterial lumen is narrowed by greater than 50%.3 Patients may be asymptomatic, even with greater than 50% blockage. A thorough examination is key to detection. This narrowing may occur as a result of atherosclerotic plaque formation, primary or secondary inflammatory states, thrombus, or a combination of these. Severity of PAD may be quantified using grading systems such as the older Fontaine system,4,5 which reports severity in terms of patient symptoms, or the more recent Rutherford categories.4,6,7 The Rutherford categories offer traditional grades that are advised for clinical use and categories that are intended for use in clinical research.7 With each of these tools, the most severe classifications are tissue loss, ulceration, and gangrene. (Tables 17.1 and 17.2)
Table 17•1Fontaine System for Grading Peripheral Arterial Disease4 |Favorite Table|Download (.pdf) Table 17•1 Fontaine System for Grading Peripheral Arterial Disease4
|Stage ||Description |
|I ||Asymptomatic |
|IIa ||Mild claudication |
|IIb ||Moderate-severe claudication |
|III ||Ischemic rest pain |
|IV ||Ulceration or gangrene |
Table 17•2Rutherford System for Grading Peripheral Arterial Disease4,6,8