Arterial trophic ulcers

Arterial trophic ulcers account for 8-12% of the total number of patients with pathology of the lower extremities. Chronic obliterating diseases of arteries of the lower extremities in total suffer 2-3% of the world population. A significant part of these patients have specific skin disorders, which accompanies a severe degree of ischemia, threatening amputation of the legs. They arise in 90% of cases against the background of obliterating atherosclerosis of the vessels of the legs and only in 10% of cases - against obliterative thrombangiitis or other causes. Arterial trophic ulcers are detected mainly in males over the age of 45 years.

The main clinical manifestation of chronic obliterating diseases of arteries of the lower extremities is "intermittent claudication" and absence of pulsation on the arteries of the feet. Arterial trophic ulcers occur on the foot or lower leg after minor injuries (rubbing, scratches, abrasions, etc.), leg operations or spontaneously.

The formation of arterial trophic ulcers is one of the most severe manifestations of ischemic lesion of the limb. The characteristic localization is the distal toes of the toes, the interdigital spaces, the rear of the foot, the calcaneal region, the outer and the back surface of the tibia. A distinctive feature is dry tissue necrosis and severe pain syndrome. In the presence of signs of critical ischemia, arterial trophic ulcers do not have clear boundaries, is surrounded by edematous cyanotic tissues, is prone to progression with the widening and deepening of the wound defect. With the further development of the ischemic process, the necrosis of the partialogy with the development of gangrene is noted.

Arterial trophic ulcers occur against a background of critical disturbance of the circulation, which is defined as vascular insufficiency of the limb, due to occlusive vascular disease in the final stages of its development. It is assumed that without the timely restoration of blood flow, further progression of ischemia will lead to the need for high amputation. The definition of critical ischemia includes the following clinical signs:

• ischemic pain of rest for more than two weeks with systolic pressure on the arteries of the tibia <50 mmHg;
• the presence of ulcerative defects or gangrene of toes with systolic pressure in the arteries of the tibia <50 mm Hg. In patients with diabetes, critical ischemia is considered cases when systolic finger pressure <30 mm Hg.

[1], [2], [3], [4], [5], [6], [7]

How are arterial trophic ulcers treated?

The use of reconstructive operations on vessels (aortoscopic, femoral-popliteal, femoral-tibial and other types of shunting), percutaneous transluminal balloon angioplasty, stenting of arteries, etc. Are considered to be the main operational methods for eliminating critical ischemia. The possibility of revascularization, the volume and nature of the operative intervention is determined after an integrated assessment of the vascular status of the legs with the help of duplex angioscanning and aortoarteriography. Isolated lumbar sympathectomy is not substantiated pathogenetically and does not affect the healing of ulcerative defects.

With extensive arterial trophic ulcers of the foot or lower leg, deep and massive necrobiotic changes in the surrounding tissues usually occur, as a result of which even successful revascularization of the limb does not lead to the desired result. The pain syndrome persists, and the extensive gangrenous-ischemic focus serves as a source of severe intoxication, which leads to the need for high amputation at the level of the shin or thigh.

Drug-induced ischemia is most effective in the use of complex therapies using prostanoids (alprostadil), disaggregants (pentoxifylline 1200 mg / day), anticoagulants (unfractionated sodium heparin, sodium enoxaparin, calcium supraparin, daleparin sodium), antihypoxants (actovegin 1000-2000 mg / day) and antioxidants (mexidol azoxime, etc.). It should be noted that conservative therapy of critical ischemia without revascularization of the legs is of little effect or the positive effect is temporary.

Most ischemic ulcer defects are classified as "black" wounds. In the treatment of arterial trophic ulcers of the finiteness of the vascular etiology, first of all, it is necessary to achieve medical or surgical correction of decompensated blood flow. Until critical ischemia is localized, it is advisable to use wet-drying dressings with solutions of antiseptics, first of all iodophores (1% solution of povidone-iodine, iodopyron, etc.) that contribute to the drying of necrosis, which is valid at this stage of treatment, and prevent the development of wound infection.

Only after the persistent elimination of the phenomena of critical ischemia do they begin to treat arterial trophic ulcers with hydrogels, which are considered one of the most effective means of tissue rehydration. The main goal of treating ulcerative-ischemic lesions of the skin of the legs is the rejection of non-viable tissues and the creation of conditions for the subsequent healing of the granulating wound. With ineffectiveness of conservative therapy or in the presence of a large array of fixed necrosis, nekrrectomy is used.

It is necessary to carefully monitor the dynamics of the wound process, the daily changing of the bandage, the use of systemic antibacterial therapy and medications that improve the rheological properties of the blood.

With a favorable course of the wound process, necrotic tissues are torn away. There is a gradual transformation of the "black" wound into "yellow", and then to "red". When the stage of the "red" wound is reached, further use of hydrogels or the transition to treatment of a wound under biodegradable wound coverings containing collagen (Digispon, Collagit, etc.), alginate, hydrocolloid and other bandages is possible.

The prospect of persistent healing of such defects as arterial trophic ulcers and the possibility of their recurrence depends on the nature of the course of the underlying disease, the possibility of adequate and timely revascularization of the limb and the balance of drug therapy. Need to give up smoking, careful care for your feet, the proper selection of shoes. With an ankle-brachial index below 0.45-0.5, epithelialization usually does not occur. In patients with an ankle-brachial index of over 0.5, the prospect of healing a ulcerative defect is much higher. It should be borne in mind that all chronic obliterating diseases of the arteries of the legs are progressive diseases with the frequent need for limb amputation at stage IV of chronic vascular insufficiency both in the group of patients who underwent revascularization and in the group of patients receiving only conservative therapy. With the development of critical limb ischemia, about half of the patients lose limb within the next 6-12 months even after successful vascular reconstruction.