Vascular ulcers are commonly encountered in the field of vascular medicine. Some ulcers are
easily diagnosed and have commonly encountered etiologies. Other ulcers may be more
difficult to diagnose and treat as sometimes uncommon etiologies manifest as ulceration of
the skin.
Diagnosis of vascular ulcers
The general approach to vascular ulcers is not different than to any other disease – it involves
taking a history, examining the patient and complementing these by targeted laboratory and
imaging studies.
Vascular ulcers – Taking a history
The following are a few tips to help in the diagnosis of vascular ulcers:

How quickly did the ulcer develop?

Why did the ulcer develop? Was there trauma? Was the ulcer a result of treatment?

Are there associated symptoms or systemic disease? Is the ulcer accompanied by other
manifestation of disease such as vasculitis or inflammatory bowel disease? Is the
patient on dialysis (is there chance for calcium deposition)? Is gout a possibility?

Did the ulcer respond to previous treatment? Lack of expected response to treatment
may point to the need to change treatment or to patient non-compliance, but may also
point to a wrong diagnosis and to the need to re-think about the ulcer.
Physical examination of ulcers
When examining a patient with an ulcer, attention needs to be paid to the ulcer and to
ancillary physical findings:

Ulcer distribution – the various ulcer types are characteristically located in typical
places. Arterial ulcers are typically found distally, at the tip of limbs or over bony
prominences. Venous ulcers are typically over the malleoli. Neuropathic ulcers are
often over pressure points on the feet. Unusual ulcer locations can either mean that
there is an unusual cause or that at least in part the ulcer is inflicted. For example,
patients with peripheral artery disease may have an ulcer at a spot where they had
even minor trauma.

Ulcer appearance – Venous ulcers are often beefy red. Arterial ulcers are clean based
(white/ischemic) or gangrenous. Neuropathic ulcers often have a callous around them
from pressure. It should be noted that many ulcers change appearance because of
previous treatment. Weird ulcer appearance should raise questions about the etiology.
For example a geometric appearance may point to contact dermatitis because of
treatment.

Edema – Swollen legs are not characteristic of arterial ulcers. Edema may accompany
venous ulcers as part of generalized venous insufficiency. Edema that accompanies an
arterial ulcer can be a sign of underlying infection, but can also be dependent edema, in
patients with arterial ulcers who dangle their feet to get better blood flow. A good
question to ask is what started first – pain or edema. If pain started first, this points to
arterial insufficiency. If the edema started first it may point to infection.
Vascular Ulcer Types
Ulcers can be divided according to their type. Knowing the etiology may be a clinical
conclusion, but sometimes a biopsy is needed.

Arterial – the term ‘pressure ulcers’ often suggests an arterial ulcer that has been
exacerbated by pressure
The signs and symptoms of ischemia vary, as it can occur anywhere in the body and depends
on the degree to which blood flow is interrupted.[4] For example, clinical manifestations of
acute limb ischemia (which can be summarized as the "six P's") include pain, pallor,
pulseless, paresthesia, paralysis, and poikilothermia.[7]
Without immediate intervention, ischemia may progress quickly to tissue necrosis and
gangrene within a few hours. Paralysis is a very late sign of acute arterial ischemia and
signals the death of nerves supplying the extremity. Foot drop may occur as a result of nerve
damage. Because nerves are extremely sensitive to hypoxia, limb paralysis or ischemic
neuropathy may persist after revascularization and may be permanent.[8]
Cardiac ischemia[edit]
Main articles: Coronary ischemia, Coronary artery disease, and Myocardial ischemia
Cardiac ischemia may be asymptomatic or may cause chest pain, known as angina pectoris. It
occurs when the heart muscle, or myocardium, receives insufficient blood flow.[9] This most
frequently results from atherosclerosis, which is the long-term accumulation of cholesterolrich plaques in the coronary arteries. In most Western countries, Ischemic heart disease is the
most common cause of death in both men and women, and a major cause of hospital
admissions.[10][11]
Bowel[edit]
Main article: Intestinal ischemia
Both large and small intestines can be affected by ischemia. The blockage of blood flow to
the large intestine (colon) is called ischemic colitis.[12] Ischemia of the small bowel is called
mesenteric ischemia.[13]