Download Download PDF. Translate PDF. To most of us involved in wound care, Keith Harding needs no introduction and his achievements are legendary. However, whether you personally know or know of Keith, you are certainly aware of his passion and commitment to wound care and its ultimate evolution into a true clinical specialty. This is recognition of an outstanding career, promoting the clinical specialty of wound care, benefiting those who suffer from both acute and chronic wounds not only in Wales but from other regions of the UK.
Professor Harding will be invited to the Buckingham Palace in the next 6 months to receive his CBE from a member of the Royal Family at an investiture ceremony. Case-report: A year-old lady with hypertension and type II diabetes mellitus underwent angiography because of a painful, non- healing ulcer over the shin, which showed multi-segment arterial occlusive disease, not amenable to surgical revascularization.
Case-report: A year-old lady with elevated blood pressure and type II diabetes mellitus underwent angiography because of a painful, non- healing ulcer over the shin, which showed multi- segment arterial occlusive disease, not amenable to surgical revascularization.
However, sticking to these criteria leg ulcers without any ischemic skin changes distal from the ankle do not fulfil the criteria of critical ischemia. We consider such cases as leg ulcers complicated but not caused by concomitant arterial occlusive disease. Martorells ulcer 5 , diabetic small vessel disease or after trauma, in whom additional occlusions of large arteries may occur.
Several studies have shown that conservative therapy or skin grafting may be successful in such cases without arterial revascularisation 6,7. In this document referral for revascularisation is recommended if the ABPI is lower than 0,5.
However, it is underlined that modified compression using stiff material may be applied with frequent reassessment and monitoring for ischemia and pressure damage. Even without any venous damage the hydrostatic pressure in the upright position promoting oedema plays always an additional triggering role. Beneficial effects of compression therapy have been demonstrated in mixed leg ulcers, to some part due to the beneficial effect of compression on the venous pathology 7.
The following case report shows that ulcer healing may be achieved also in arterial leg ulcers without venous insufficiency. Case report A year-old lady presenting a painful ulcer over the left shin came to the office of C. ABPI was 0. She never smoked. An attempt to neovascularize the left leg was not undertaken because of the poor arterial situation showing additional distal arterial occlusions and the patient was dismissed from the hospital after 2 weeks and was advised to cover the wound with non-adhering local dressings and to avoid any kind of compression.
At the first visit in the office a sharply demarcated, fairly circular ulcer over the proximal shin was presented largest diameter x 4 cm which was around 5 mm deep, and showed some black, necrotic slough at the basis. The peri-wound skin showed some inflammatory signs like reddening and oedema but no signs of chronic venous insufficiency, like lipodermatosclerosis or pigmentation were present.
The ulcer was extremely painful, the patient avoided to walk and spent her day preferably in the sitting position. No varicose veins were visible and no refluxes were detected over superficial or deep veins using a Doppler probe Duplex would have been preferred but is not available in the office of the General Practitioner who treated the patient. Swab cultures were taken and revealed a growth of Pseudomonas aeruginosa Additionally, to type II diabetes the patient suffered from hypertension, asthma and coxarthrosis, BMI was Drug- therapy Hypertension was treated by the AT1 receptor blocker Olmesartan 40 mg, diabetes was controlled by diet and Metformin.
The statin Rosuvastatin was given to control dyslipidaemia, Clopidogrel as an antiplatelet drug. Paracetamol was given as a pain-killer during the first 2 months. After 2 months the colonisation with pseudomonas disappeared without antimicrobial therapy. Patient reported less pain and the bandages were left day and night on the leg. During this period resting pressure measured under the pads by a Kikuhime-transducer was around 50 mm Hg immediately after bandage- application.
Fig 3 demonstrates the healing process. After 4 months the ulcer was healed and the patient was free from pain and could walk slowly without any restriction. Gauze must remain moist between dressing changes.
Do not confuse this with a wet to dry dressing which can mechanically debride both necrotic and healthy tissue. If healing is stalled; advance therapies and adjuncts should be considered. Open navigation menu. Close suggestions Search Search. User Settings. Skip carousel. Carousel Previous.
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Jump to Page. Search inside document. The positive development was demonstrated by daily photographs which reassured also the patient, who followed the advice to walk as much as possible with increasing concordance.
Ultimately the ulcer was healed after 4 months. Doppler sonography showed a clear qualitative improvement of the arterial sounds of the distal pulses which changed from a monophasic into a biphasic pattern and an increase of the ankle pressure, reflected by an increment of the ABPI from originally 0,54 to 0,7. Up to now such long term improvements of the arterial circulation due to the development of collaterals could be shown after intermittent pneumatic compression in severe cases with arterial occlusive disease, but not after wearing compression bandages and walking In acute experiments, both in healthy subjects 13 but also in patients with arterial occlusive disease recent publications demonstrated an increase of the arterial flow 7.
This is true as long the compression pressure does not exceed the local arterial perfusion pressure. Several mechanisms of action are discussed which may explain an increase of the arterial flow under compression: auto- regulatory response to the decrease of transmural pressure gradient and a myogenic relaxation in the arterial wall, a vasodilatory axon reflex response, mediated by nervous and biomechanical signals, and a reduction of arterio-venous pressure gradient by improvement of venous return, especially in combination with walking exercises.
Oedema reduction by compression will reduce the distance between the capillaries and the tissue cells thereby shortening the way the nutrients must pass to reach their target cells.
Bringing the blood capillaries in closer contact with the cells will lead to an improvement of nutrition 17 Inelastic compression together with walking creates a rhythmic massage which resembles the effects of intermittent pneumatic pumps resulting in a release of vasoactive mediators from the venular endothelial cells due to the pulsating increase of the shear stress in the microcirculatory flow 11 In contrast to elastic material which would not be tolerated with an initial resting pressure of around 50 mmHg there is an immediate pressure loss due to instant oedema reduction.
In addition to these local compression effects also an improvement of the venous pumping function may be taken into consideration, although the venous pump is not damaged It seems very improbable that the accompanying medication which has been taken already before compression had been initiated played a role for the documented reduction of oedema and inflammation, and for the flattening and healing of the ulcer. Our case-report demonstrates that this will lead to an improvement of arterial flow so that arterial leg ulcers may heal.
References 1. Chapter I: Definitions, epidemiology, clinical presentation and prognosis. Eur J Vasc Endovasc Surg. Int Angiol. Management of mixed arterial and venous leg ulcers. Br J Surg. Martorell hypertensive ischemic leg ulcer: a modelof ischemic subcutaneous arteriolosclerosis.
Arch Dermatol. Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization. J Vasc Surg. Venous reflux surgery promotes venous leg ulcer healing despite reduced ankle brachial pressure index. Compression therapy in mixed ulcers increases venous output and arterial perfusion. Harding K et al. Simplifying venous leg ulcer management.
Consensus recommendations Wounds International Chronic venous disease.
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