mark finkelstein dpm board-certified, american board of podiatric surgery board-certified, american...

Ulcerations Due to Peripheral Vascular Disease

Mark Finkelstein DPM

Board-Certified, American Board of Podiatric Surgery

Board-Certified, American Board of Podiatric Medicine

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

Arterial Ulcer CharacteristicsLocated on bony prominences of the legs and

feet“Punched-out” appearance with well-defined

bordersShiny atrophic skin, no hair growthLittle/no edema or wound exudateYellow slough or black eschar in the wound

bed with little granulation tissueFeet are cool to touch and pedal pulses are

often not palpable

Arterial Ulcer Characteristics

Assessment of Pedal Pulses

Vascular Assessment-Clinical

Elevation Pallor

Dependent Rubor

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

Treating The Arterial Wound

•Do not debride dry, stable eschar until perfusion status is determined

•For ulcers with insufficient flow, maintain dry, stable eschar

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

Vascular assessment•Noninvasive vascular testing

Vascular Assessment• Evaluate vascular status with angiogram

Vascular treatment•Endovascular- Techniques

Vascular treatment•Surgical Bypass-

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

Multidisciplinary approach1. Medical therapy- beta blockers, statins,

ACE inhibitors and antiplatelet therapy

2. Teach chronic disease management

4. Tobacco cessation programs

3. Optimize nutrition

5. Evaluate functional, cognitive and emotional state of the patient

Multidisciplinary approach

• Increase regular exercise and physical activity to improve symptoms of claudication

• Proper pain control of ulcerations

Arterial ulcers -SummaryRequires a multidisciplinary approach for proper management

1. Wound Care Specialist-Podiatrist, Wound Nurse2. Vascular /Interventional Radiologist3. Vascular surgeon4. Primary Care Physician5. Dietitian6. Mental Health Provider7. Orthotist8. Physical Therapist9. Pain Management Specialist

Arterial ulcerations

QUESTIONS

THANK YOU