OTTAWA — Determine the vascular supply to a limb as the first step in the treatment of a lower extremity wound, Dr. Stephan Mostowy said at the annual conference of the Canadian Association of Wound Care.
Early identification of a wound's etiology and assessment of a patient's risk factors can give the patient the best chance to heal, he said. “The overall incidence of vascular disease is growing as our population ages,” but only 10% of patients are symptomatic, said Dr. Mostowy, a vascular surgeon at Credit Valley Hospital in Mississauga, Ont.
Smoking, hypertension, and hyperlipidemia are common culprits in peripheral vascular disease, so physicians should consider arterial insufficiency in patients with these risk factors who present with leg wounds, he said.
In addition to a physical exam and checking pulses, an ankle brachial index (ABI) of less than 0.9 mm Hg can indicate peripheral vascular disease because it demonstrates decreased blood flow to the legs. In some cases, a vascular surgeon can improve the blood flow to the wounded area and improve the patient's chances for healing.
“Working in a multidisciplinary team is crucial to improving rates of healing in our patients,” emphasized Dr. Mostowy and Laurie Goodman, a clinical wound care specialist at the hospital. Dr. Mostowy and Ms. Goodman copresented three cases that are typical of wounds with three different etiologies: arterial, venous, and diabetic.
Surgery Needed
Dr. Mostowy began with the case of a 74-year-old male smoker who had diabetes, hypertension, and hypercholesterolemia. The patient presented with a painful, pale, and punched-out ulcer on the back of his calf. He had no discernible pulses in the lower leg, which was cool to the touch, and he had a reduced ABI of 0.3 mm Hg, which suggested arterial insufficiency.
By contrast, venous ulcers are usually shallower than arterial wounds, and they are often located on the lower leg just above the ankle and below the calf (the “gaiter” area), Dr. Mostowy said. Venous ulcers also are more likely to be associated with varicose veins, he added.
Surgery (femoral-distal bypass) was the appropriate choice for this patient to improve his blood supply and heal the lesion. The procedure involved making two incisions in the patient's leg and harvesting an arm vein to use as a conduit.
The result was a well-healed ulcer that was completely closed and pain free after a few weeks. The patient also quit smoking, which will help the long-term durability of the bypass, Dr. Mostowy noted.
A Very Venous Problem
The next case involved a 39-year-old male with a recurrent venous ulcer on his left leg. The patient was a professional cook and a single father, and was standing all day. He had a history of varicose veins and deep venous insufficiency from a similar ulcer 2 years ago that had healed, but he was nonadherent about wearing the compression stocking that was necessary to keep his leg healthy, Dr. Mostowy said.
The patient presented with a new ulcer that was so infected and advanced that he was hospitalized for wound management and pain relief. He had strong digital pulses suggestive of a normal arterial supply, indicating a venous etiology rather than arterial, Dr. Mostowy explained.
The patient underwent surgical wound debridement, received intravenous antibiotics, and had dressing changes. Once the ulcer was under control, he was treated as an outpatient with a four-layer compression system of dressing, which addressed his venous hypertension. The use of analgesia and an airbed made a significant difference in his comfort at home and reduced his pain to a 5 on a 10-point scale.
When the ulcer was nearly healed, the patient was matched with a compression stocking supplier to help him transition to a stocking with better compliance. This case is an example of a successful team effort to heal the ulcer. “Hopefully, this patient is better educated and will wear the compression stocking to prevent future recurrences,” Dr. Mostowy said.
Diabetic Foot Fix-Up
The third case involved a 63-year-old woman who “arrived at the emergency department with a terrible diabetic foot infection,” Dr. Mostowy said.
The patient had pus draining from the bottom of her foot, and she had a fever and chills. The wound required surgical draining of the plantar space and amputation of the fourth and fifth toes to control the infection. After the area was drained, the wound was stabilized with antibiotics and a local dressing and the wound care team assessed the vascularity of the wound to determine the potential for healing.