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Background


Peripheral vascular disease (PVD) is any disease that affects the blood flow through veins and arteries distal to the heart. Peripheral arterial disease affects the arteries only1. Peripheral arterial disease (PAD) is a life-threatening condition which results from the narrowing of the blood vessels.”2

Patients with arterial disease often have a history of cerebral vascular accident (stroke), coronary artery disease or diabetes3 4 5. Cigarette smokers, the elderly and those with high blood pressure are at particular risk for developing PAD. Arterial leg ulcers usually result from trauma, pressure, thermal extremes, chemicals, blood clot/embolus or infection in this susceptible population6. Ischemia is a restriction of blood supply caused by stenosis (narrowing) or occlusion (blockage) of the blood vessel leading to damage of the surrounding tissue. Hypoxia occurs when tissue is deprived of oxygen. Both ischemia and hypoxia can cause critical limb ischemia which can lead to the need for limb amputation and/or death7.

It is estimated that between 14-20% of the adult population will develop peripheral arterial disease in their lifetime8. Nearly 10% of all patients that present with leg or foot ulcers have ‘pure arterial insufficiency’9. Critical limb ischemia occurs in approximately 3% of patients that develop PAD10 11. The ten year mortality rate of those with PAD is 60%. The five year mortality rate of those patients that experience critical limb ischemia is 50 to 70%12 13.

Inadequate tissue perfusion can result in formation of arterial ulcers due to partial or complete blocking of arterial flow. These ulcers, which are usually found on the lower legs and feet, are very often painful and difficult to heal14.

Patients with arterial ulcers often suffer from a significant decreased level of quality of life. Pain, which can be described as ‘worst pain possible’, can make mobility and sleep difficult or nearly impossible. Independence can be affected, often rendering caregivers to become care receivers. Physical limitations can cause issues with performing housework, employment requirements and other activities of daily living15. Difficulty working can have a financial impact on patients’ lives, affecting job security and possibly causing the need to retire earlier than planned. Problems sleeping can create a negative state of well-being, anxiety and depression. Personal hygiene can be a challenge for patients with arterial ulcers. Limited mobility and fear of further injury may lead to a decrease in personal hygiene. Wound odour may leave the patient with a sense of uncleanliness. Many feel that their sex life is negatively affected by having an arterial ulcer16 17.

The diagnosis and prognosis of arterial disease can cause patients to become very fearful of the possibility of amputation, discrimination and social rejection. Self-image can be affected as concerns of tissue decay and body weakness are known to cause feelings of discomfort, shame and fear. Patients often go out less frequently, reducing interaction time with family and friends. Social isolation can result in feelings of embarrassment, sadness, anger and decreased self-esteem. These patients often develop avoidance strategies to prevent further injury or pain. They may avoid crowds, having children on their laps, interaction with pets, taking vacations, gardening and other leisure activities18 19.

From April 2013 until March 2014, arterial leg ulcer nursing care in Waterloo Wellington cost home and community care over one hundred thousand dollars. A significant number of nursing visits were required for over 56 patients with arterial leg ulcers at an average cost per client of $1944. The average length of stay requiring community wound care for patients with arterial leg ulcers in Waterloo Wellington was 129 days20.


Best Practices for Assessment, Prevention, and Treatment of Arterial Leg Ulcers

Evidence-based practice can be defined as a “process for making informed clinical decisions. Research evidence is integrated with clinical experience, patient values, preferences and circumstances.”21 This process allows for professional judgement to become professional standards of practice.

Although the Registered Nurses Association of Ontario (RNAO) does not have best practice guidelines specific for arterial leg ulcers, some very useful information regarding best practice recommendations for arterial leg ulcers can be found in the RNAO Assessment and Management of Venous Leg Ulcers guidelines and the 2007 supplement22 23.

Recently in 2014, Sibbald et al published two peer-reviewed articles in Advances in Skin and Wound Care addressing clinical diagnosis, investigation and treatment of arterial disease ulcers. Information gleaned from these two papers can be found throughout these recommendations24 25.


Wound Bed Preparation Paradigm

The wound bed preparation (WBP)26 paradigm is used to assess, diagnosis, and treat wounds while considering patient concerns. It links evidence-based literature, expert opinion, and clinical experiences of respected wound care specialists. The framework is beneficial because the components are interrelated and can be re-evaluated if the wound deviates from the care plan. Furthermore, the interprofessional team is able to collaborate together through shared discussion to classify a healable, maintenance, and non-healable wound.


Figure 1 - Wound Bed Preparation Paradigm27 28

Wound Bed Preparation Paradigm figure

Address Patient-Centred Concerns
  1. Miller-Keane. Encyclopedia and Dictionary of Medicine, Nursing and Allied Health – Seventh edition. Saunders Publishing 2003.
  2. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  3. Zaidi Z, Lanigan SW. Leg Ulcers. In: Zaidi Z, Lanigan SW, eds. Dermatology in Clinical Practice. New York, NY: Springer, 2010:622.
  4. Criqui MH. Peripheral arterial disease--epidemiological aspects. Vasc Med 2001;6:3-7.
  5. Federman DG, Kravetz JD. Peripheral arterial disease: diagnosis, treatment, and systemic implications. Clin Dermatol 2007;25:93-100.
  6. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  7. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  8. Smith FCT, Sharma P, Kyriakides C. Natural history and medical management of chronic lower extremity ischemia. In: Hallett JW, Mill JL, Earnshaw JJ, Reekers JA, Rooke TW, eds.
  9. Young JR. Differential diagnosis of leg ulcers. Cardiovasc Clin 1983;13:171-93.
  10. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45 Suppl S:S5-67.
  11. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006;47:1239-312.
  12. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45 Suppl S:S5-67.
  13. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006;47:1239-312.
  14. Soares P.P.B, Ferreira L.A, Gonfalves J.R. L, Zuffi F.B. Impact of Arterial Ulcers in the Quality of Life Through the Perception of Patients. Journal of Nursing UFPE On Line 7(8):5225-31. August 2013.
  15. Soares P.P.B, Ferreira L.A, Gonfalves J.R. L, Zuffi F.B. Impact of Arterial Ulcers in the Quality of Life Through the Perception of Patients. Journal of Nursing UFPE On Line 7(8):5225-31. August 2013.
  16. Budgen V. Evaluating the Impact on Patients Living with a Leg Ulcer. Nursing Times Publication. February 17 2004.
  17. Herber O.R, Schnepp W, Rieger M.A, A Systematic review on the impact of leg ulceration on patients’ quality of life. Health and Quality of Life. July 2007.
  18. Soares P.P.B, Ferreira L.A, Gonfalves J.R. L, Zuffi F.B. Impact of Arterial Ulcers in the Quality of Life Through the Perception of Patients. Journal of Nursing UFPE On Line 7(8):5225-31. August 2013.
  19. Herber O.R, Schnepp W, Rieger M.A, A Systematic review on the impact of leg ulceration on patients’ quality of life. Health and Quality of Life. July 2007.
  20. Waterloo Wellington Community Care Access Centre. Current-State Assessment. February 2014.
  21. Woodbury M.G, Kuhnke J.L. Evidence-based Practice vs. Evidence-informed Practice. Wound Care Canada. Volume 12, Number 1. Spring 2014.
  22. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004.
  23. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007.
  24. Weir G.R, Hiske S, Marle J.V, Cronje F.J. Arterial Disease Ulcers, Part 1: Clinical Diagnosis and Investigation. Advances in Skin and Wound Care: September 2014.
  25. Weir G.R, Hiske S, Marle J.V, Cronje F.J, Sibbald R.G. Arterial Disease Ulcers, Part 2: Treatment. Advances in Skin and Wound Care: September 2014.
  26. Burrows C, Miller R, et al. Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers: Update 2006. Wound Care Canada. 2006;4(1).
  27. Sibbald R.G, Orstead H.L, Coutts P.M, Keats D.H. Best Practice Recommendations for Preparing the Wound Bed: Update 2006. Wound Care Canada. Volume 4 Number 1. 2006
  28. Weir G.R, Hiske S, Marle J.V, Cronje F.J, Sibbald R.G. Arterial Disease Ulcers, Part 2: Treatment. Advances in Skin and Wound Care: September 2014

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