Arterial trophic ulcers

Arterial trophic ulcers account for 8-12% of the total number of patients with lower limb pathology. Chronic obliterating diseases of the arteries of the lower limbs affect 2-3% of the world's population. A significant portion of these patients have specific skin disorders, which are accompanied by a severe degree of ischemia, threatening amputation of the legs. They occur in 90% of cases against the background of obliterating atherosclerosis of the leg vessels and only in 10% of cases - against the background of obliterating thromboangiitis or other causes. Arterial trophic ulcers are detected mainly in males over 45 years of age.

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

Formation of arterial trophic ulcers is one of the most severe manifestations of ischemic limb damage. Typical localization is the distal parts of the toes, interdigital spaces, dorsum of the foot, heel area, outer and back surface of the leg. Distinctive features are dry tissue necrosis and severe pain syndrome. In the presence of signs of critical ischemia, arterial trophic ulcers do not have clear boundaries, are surrounded by edematous cyanotic tissues, and are prone to progression with expansion and deepening of the wound defect. With further development of the ischemic process, necrosis of part of the leg with the development of gangrene is noted.

Arterial trophic ulcers occur against the background of critical circulatory failure, which is defined as vascular insufficiency of the limb, due to occlusive vascular damage in the final stages of its development. It is implied that without 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 at rest for more than two weeks with systolic pressure in the arteries of the lower leg <50 mm Hg;
• the presence of ulcerative defects or gangrene of the toes with systolic pressure in the arteries of the lower leg <50 mm Hg. In patients with diabetes mellitus, critical ischemia is considered to be cases when the systolic digital pressure is <30 mm Hg.

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How are arterial trophic ulcers treated?

The main surgical methods for eliminating critical ischemia are considered to be the use of reconstructive operations on vessels (aortofemoral, femoropopliteal, femorotibial and other types of bypass), percutaneous transluminal balloon angioplasty, arterial stenting, etc. The possibility of revascularization, the volume and nature of surgical intervention are determined after a comprehensive assessment of the vascular status of the legs using duplex angioscanning and aortoarteriography. Isolated lumbar sympathectomy is not pathogenetically justified and does not affect the healing of ulcerative defects.

In case of extensive arterial trophic ulcers of the foot or shin, 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 to perform high amputation at the level of the shin or thigh.

Drug relief of ischemia is most effective when using complex therapy with prostanoids (alprostadil), antiplatelet agents (pentoxifylline at a dose of 1200 mg/day), anticoagulants (unfractionated sodium heparin, sodium enoxaparin, calcium nadroparin, sodium dalteparin), antihypoxants (actovegin 1000-2000 mg/day) and antioxidants (mexidol, azoximer, etc.). It should be noted that conservative therapy of critical ischemia without revascularization of the legs is ineffective or the positive effect is temporary.

Most ischemic ulcerative defects are classified as "black" wounds. In the treatment of arterial trophic ulcers of the limb of vascular etiology, it is first necessary to achieve drug or surgical correction of decompensated blood flow. Until critical ischemia is locally relieved, it is advisable to use wet-drying dressings with antiseptic solutions, primarily iodophors (1% povidone-iodine solution, iodopyrone, etc.), which contribute to the drying of necrosis, which is justified at this stage of treatment, and prevent the development of wound infection.

Only after stable elimination of critical ischemia phenomena, treatment of arterial trophic ulcers with hydrogels is started, which are considered one of the most effective means of tissue rehydration. The main goal of treatment of ulcerative-ischemic lesions of the skin of the legs is the rejection of non-viable tissues and the creation of conditions for subsequent healing of the granulating wound. If conservative therapy is ineffective or in the presence of a large array of fixed necrosis, necrectomy is used.

Careful monitoring of the dynamics of the wound process, daily dressing changes, the use of systemic antibacterial therapy and medications that improve the rheological properties of the blood are necessary.

With a favorable course of the wound process, necrotic tissue rejection occurs. A gradual transformation of the "black" wound into a "yellow" one, and then into a "red" one occurs. Upon reaching the "red" wound stage, further use of hydrogels or transition to wound treatment under biodegradable wound dressings containing collagen ("Digispon", "Collahit", etc.), alginate, hydrocolloid and other dressings are possible.

The prospect of stable healing of such defects as arterial trophic ulcers and the possibility of their recurrence depend on the nature of the underlying disease, the possibility of adequate and timely revascularization of the limb and the balance of drug therapy. It is necessary to quit smoking, carefully care for your feet, and choose the right shoes. With an ankle-brachial index below 0.45-0.5, epithelialization usually does not occur. In patients with an ankle-brachial index above 0.5, the prospect of healing of the ulcer defect is much higher. It is necessary to take into account that all chronic obliterating diseases of the arteries of the legs are progressive diseases with a 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 who received only conservative therapy. With the development of critical limb ischemia, about half of the patients lose the limb within the next 6-12 months even after successful vascular reconstruction.