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Progressive vascular disease affects millions of individuals worldwide. In the US alone over 8.5 million individuals suffer from peripheral arterial disease (PAD) and more than 6 million have chronic venous insufficiency (CVI) [1,2]. Over many years, these diseases injure arteries and veins and disrupt healthy blood flow in the body. This eventually damages tissues such as muscles, nerves, and skin that rely on this blood supply. As the disease progresses, clinically complex symptoms like pain, functional limitations, and skin ulceration may occur.

In fact, vascular disease causes >90% of chronic leg ulcers, with approximately 70% caused by venous insufficiency, 5-10% caused by arterial disease, and up to 26% having a mixed arterial and venous etiology [3,4]. These facts may be particularly surprising if you’ve looked to a dermatologist, podiatrist, or a wound specialist in the past to manage ulcers.

Arterial ulcer and venous ulcer specialist Dr. Michael Lalezarian in Los Angeles, California

Your Vascular Partner

Dr. Michael Lalezarian

Timely, accessible care is paramount in the effort against arterial ulcers, venous ulcers, and their complications.

Dr. Michael Lalezarian is a double-board certified Vascular Interventional Radiologist specializing in minimally invasive endovascular arterial revascularization. He is a committed partner in the battle against the devastating consequences of advanced vascular disease.

5-Star Arterial Ulcer and Venous Ulcer care in Los Angeles
“He is truly dedicated, and an extraordinary physician who’s really concerned with his patients!”

Adrianne S, October 2018

What Causes Arterial vs Venous Ulcers?

Arteries and veins work together to bring blood towards and away from all parts of the body. Dysfunction of either part of this system can have the common outcome of skin ulceration.

What Causes Arterial Ulcers?

In arteries, plaque accumulation and hardening of the arteries from smoking, high blood pressure, cholesterol build-up, diabetes mellitus, obesity, or other vascular disease causes narrowing of medium and large arteries, limiting the forward flow of blood [5]. This process leads to recurrent muscle fatigue, cramping, and pain referred to as “intermittent claudication” [5,6]. In cases of severe ischemia, the tissue normally supplied by the narrowed artery begins to die, leading to ulcer formation. Older individuals and those with diabetes are at an increased risk of being affected, despite the underdiagnosis that is associated with this disease [6].

What Causes Venous Ulcers?

In the veins, complications develop from an increase in venous pressure caused by either impaired functioning of 1-way valves within the veins, obstruction of these vessels, or dysfunction of the muscles that support the pumping of blood through these veins. Occurring alone or in combination, these mechanisms impair the flow of blood back towards the heart. The back-up of blood stresses the venous system with increased volume and pressure, past its natural reservoir capacity. This causes skin color changes and breakdown of the overlying tissue, such as fat [2,7]. Significant risk factors for first time venous leg ulcer formation include an older age, a higher body mass index, low physical activity, arterial hypertension, deep vein reflux, deep vein thrombosis, and a family history of venous leg ulcers [8]. In about a quarter of individuals, both arterial and venous disease processes are present, adding to the complexity of management.
Comparison of deep arterial ulcer on leg and shallow venous ulcer on foot
Your Partner in Vascular Care
PAD Specialist in Los Angeles

What is the Difference Between Arterial & Venous Ulcers?

While destruction of the skin and underlying tissues is a feature of both diseases, arterial ulcers and venous ulcers are clinically different in terms of how they present, what they look like, and what the affected individual experiences.

Arterial Ulcer Signs & Symptoms

Patients with artery disease often present with aching pain that is worsened by activity and relieved with rest [5]. With severe disease, pain can persist even at rest. There is also an increased amount of destruction of the skin that causes it to breakdown and form ulcers. Arterial ulcers normally occur past the point of compromised blood supply, usually at the farthest parts of the body such as feet, toes, fingers, side of the ankle, and areas of pressure to the skin. Arterial ulcers may be shallow or deep with sharp “punched out” borders. Oftentimes, the wound base is grey or yellow with associated gangrene and eschar (dry dark scab). Tissue surrounding the wound may be itchy, pale, and shiny [4,9,10]. These characteristics are very distinct from venous disease.

Venous Ulcer Signs & Symptoms

Patients with vein disease have a varied combination of signs and symptoms. Initially, they experience edema, or swelling, past the area of blockage, fatigue, itching, cramping, and pain that improves with rest and leg elevation [2]. Importantly, venous symptoms are not associated with exercise. As the severity increases, other signs of venous insufficiency are observed, such as spider veins or “telangiectasias”, varicose veins, constant swelling, fat destruction or “lipodermatosclerosis”, and destructive skin changes usually at the lower third of the leg, but anywhere between the knee and ankle [4,9,10,11]. Skin at this point often appears pale, hard, hyperpigmented, hairless, and thin or ulcerated [4]. Venous ulcers are shallow and irregularly shaped with red granular tissue, fibrinous material, and sometimes calcification. [3,9] Pain is usually less severe with venous ulcers than arterial ulcers. Arterial ulceration is also associated with greater clinical severity and comorbidity.
Your Partner in Vascular Care
PAD Specialist in Los Angeles

Treatment Options for Arterial vs Venous Ulcers

The treatment of vascular ulcers focuses on healing not only the visible ulcer, but also addressing the underlying disease processes that created them. While treatment approaches differ greatly between arterial and venous ulcers, care must be taken in both cases to minimize the risk of infection and manage active wounds.

Arterial Ulcer Treatment

In arterial disease, the initial focus of treatment is on modifying risk factors through lifestyle changes and medications. For symptomatic disease, minimally invasive procedures and more invasive surgical options exist that improve blood delivery past the arterial narrowing or blockage. Procedural approaches to arterial disease are commonly referred to as revascularization because the end goal is to re-vascularize the affected extremity. A variety of minimally invasive tools may be used to open up blocked arteries and heal arterial ulcers. These can include atherectomy, angioplasty, and stenting, among others. For severe disease that cannot be addressed with minimally invasive techniques, arterial bypass surgery, endarterectomy, and even amputation surgery may be offered. These interventions, though invasive, can greatly alleviate symptoms and improve quality of life [5].

Venous Ulcer Treatment

Treatment for patients with venous disease is centered on reducing swelling through leg elevation and compression therapy, eliminating varicose veins, and improving flow in the deep veins if necessary. [2,4] Management also includes lifestyle changes such as exercise and weight loss to improve blood flow through the veins. Varicose veins can be addressed with minimally invasive vein closure or surgical vein stripping. Varicose vein treatment alone may be sufficient to allow venous ulcers to heal, but for more progressive disease that fails to respond to minimally invasive strategies, surgical options may be offered. For example, valves within deep veins can be fixed using reconstruction and transplantation; or bypass surgery may be offered in the case of an intractable flow obstruction [2,7].
Arterial ulcer blood flow before and after revascularization therapy
Image of a major artery in the leg of an ulcer patient before arterial revascularization (blood flow blocked) and after arterial revascularization (blood flow restored).

Your Partner in Vascular Care

PAD Specialist in Los Angeles

Who Treats Vascular Ulcers?

Vascular ulcers are best treated through a multidisciplinary team approach involving physicians and nurses specializing in vascular medicine, wound care, bariatrics, and physical therapy [2]. Various types of physicians specialize in the care of vascular disease including general surgeons, vascular surgeons, and interventional radiologists. Interventional radiologists specialize in minimally invasive approaches to improving blood flow, while surgeons are best-suited to treat more progressive disease through more invasive surgeries.

Vascular Ulcer Care in Los Angeles

At ProVascularMD, we provide minimally invasive treatment to heal arterial and venous ulcers. Our vascular and interventional radiologists specialize in revascularization techniques to treat peripheral artery disease, and vein closure treatment for venous insufficiency. Give us a call today to schedule your visit!
More Resources
Peripheral Artery Disease Screening: Why Early Detection is Critical in PAD
Peripheral Artery Disease Screening: Why Early Detection is Critical in PAD
PAD signs, symptoms, risk factors, and screening methods.
Endovascular Treatment of Lower Extremity Arterial Disease
Endovascular Treatment of
Lower Extremity Arterial Disease
A brief 101 on the treatment options available for arterial disease.
Los Angeles Vascular Specialist Dr. Michael Lalezarian
Vascular Specialist in Los Angeles
Learn more about Los Angeles Vascular Specialist Dr. Michael Lalezarian.
References

[1] Peripheral Arterial Disease (PAD) Fact Sheet. Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_pad.htm. Accessed November 25, 2019.
[2] Patel SK, Surowiec SM. Venous Insufficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. http://www.ncbi.nlm.nih.gov/books/NBK430975/. Accessed November 25, 2019.
[3] Agale SV. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers. 2013;2013:1-9.
[4] Hedayati N, Carson JG, Chi Y-W, Link D. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med. 2015;20(5):479-486.
[5] Conte SM, Vale PR. Peripheral Arterial Disease. Heart, Lung and Circulation. 2018;27(4):427-432.
[6] Shu J, Santulli G. Update on peripheral artery disease: Epidemiology and evidence-based facts. Atherosclerosis. 2018;275:379-381.
[7] Eberhardt RT, Raffetto JD. Chronic Venous Insufficiency. Circulation. 2014;130(4):333-346. doi:10.1161/CIRCULATIONAHA.113.006898
[8] Meulendijks AM, de Vries FMC, van Dooren AA, Schuurmans MJ, Neumann HAM. A systematic review on risk factors in developing a first‐time Venous Leg Ulcer. J Eur Acad Dermatol Venereol. 2019;33(7):1241-1248.
[9] Salcrido, R. C. Arterial vs Venous Ulcers: Diagnosis and Treatment: Advances in Skin & Wound Care. 2001;14(3):146-147.
[10] Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006;332(7537):347-350.
[11] Dean SM. Cutaneous Manifestations of Chronic Vascular Disease. Progress in Cardiovascular Diseases. 2018;60(6):567-579.

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