VASCULAR WOUNDS PATHOPHYSIOLOGY AND MANAGEMENT

Transcription

1 VASCULAR WOUNDS PATHOPHYSIOLOGY AND MANAGEMENT Lucy Stopher, A/CNS Vascular Surgery

2 ...it is best to think of a wound not as a disease, but rather as a manifestation of disease. Joe McCulloch

3 In order to manage wounds effectively, it is essential to manage the underlying cause.

4 CIRCULATORY SYSTEMS Arterial Venous Lymphatic

5 Arterial Insufficiency Atherosclerosis develops in the arteries supplying the legs This results in diminished blood supply to the tissue Wounds caused by trauma or pressure are much less likely to heal when blood supply is diminished

6 Arterial Insufficiency

7 Signs of Arterial Insufficiency Pale, cool skin Minimal or no hair growth Diminished pulses Pain usually described as cramping muscles or pain in the foot either at rest or after walking/exercise (claudication)

8 Stages of Arterial Insufficiency

9 Arterial Insufficiency

10 Characteristics of arterial ulcers Arterial ulcers are usually: Deep and punched out Painful, especially when elevated Over bony prominences

11 Arterial Ulcers

12 Investigations Noninvasive Invasive Doppler ultrasound ABI Clinical Assessment Pulses Colour Temperature Movement Sensation Capillary refill Hair loss CT angiogram MR angiogram Diagnostic angiogram

13 Arterial wound management Prior to revascularisation, wound management should be conservative. The aim is to keep the wound free of infection Adequate pain relief should be provided Once blood supply is restored moist wound healing should be encouraged

14 Treatment Options The only way to heal an arterial ulcer is to improve the blood supply Angioplasty/stent: A catheter is passed through the femoral artery and an attempt is made to balloon the narrowing's open Bypass: A vein or synthetic graft is used to bypass the blocked artery Amputation is required once too much tissue is damaged

15 Treatment Options

16 Venous Insufficiency There are valves in the veins that open and close to push blood back up to the heart. These valves can stop working efficiently and fluid accumulates in the lower leg, this is known as chronic venous insufficiency. As the fluid builds up in the lower leg it puts pressure on the skin. The skin then becomes fragile and breaks down causing a non-healing ulcer.

17 Causes of venous insufficiency Venous Insufficiency can be caused by: previous DVT varicose veins genetics

18 Signs of venous insufficiency Lower limb oedema Hyperkeratotic skin scale build up Haemosiderin staining brown staining on the skin Large, shallow ulcer Often minimal complaints of pain

19 Venous ulcers

20 Investigations Ultrasound of the veins is required to assess whether the deep or superficial veins are the cause of the non-healing ulcer.

21 Management of venous ulcers Compression bandaging is essential to decrease oedema and allow the ulcer to heal Moist wound healing should be maintained Infection should be managed with antimicrobial dressings The patient should be encourage to walk regularly to promote the use of the calf muscle pump to decrease oedema

22 Management of venous ulcers

23 Treatment options If the superficial veins are incompetent they can be surgically removed or treated to prevent further ulceration If the deep veins are incompetent the only management is compression bandages if there is an ulcer, then lifelong compression stockings once the ulcer has healed

24 Neuropathic Ulcers Peripheral neuropathy is damage to the peripheral nerves that causes change in sensation and strength This is mainly caused by diabetes Neuropathic ulcers develop because the foot becomes numb and the patient doesn t notice ongoing pressure causing an ulcer

25 Testing for neuropathy

26 Characteristics of Neuropathic Ulcers Bony and/or plantar aspect of foot Surrounding built up callous Malodour common

27 Neuropathic Ulcers

28 Management of neuropathic ulcers Offloading the weight from the wound is crucial to wound healing. Podiatrists can provide footwear to assist with this. Moist wound healing should be maintained unless blood supply is diminished.

29 Diabetic Foot ulcers develop due to: Impaired healing Neuropathy Arterial insufficiency

30

31 Diabetic foot ulcers Usually develop from trauma/pressure Require aggressive management to: Offload pressure Prevent infection Fix any arterial insufficiency Amputation is performed once the bone is infected (osteomyelitis)

32

33

34

35

36

37

38

39

40

41

42 Summary Understanding the underlying disease is essential to heal the wound Thorough assessment is required to diagnose Treatment of the underlying disease will heal the wound