Vascular - Mixed Aetiology Ulcers

What are the aims of the leaflet?

This leaflet has been written to help you understand more about your mixed aetiology (venous and arterial) leg ulcer, the causes, treatment and prevention.

What causes a mixed aetiology leg ulcer?

Mixed aetiology leg ulcers are caused by problems to both your arteries and your veins.

Arteries are blood vessels which carry blood from the heart to your legs and veins are blood vessels that carry blood back to your heart. To prevent this blood back-flowing to your feet, the veins have one-way valves.

Mixed aetiology ulcers can therefore develop when the arteries become blocked or narrowed (arteriosclerosis) leaving the skin starved of vital oxygen and nutrients and when the valves become damaged, blood can flow the wrong way. This causes the veins to become over stretched and congested.

A leg with damaged veins may also become swollen, tender to touch, have brown staining, have prominent veins (varicose veins), feel itchy or dry and may be painful. Similarly, pain can be experienced when walking which is relieved by rest; this is known as ‘intermittent claudication’.

This occurs as a result of narrowing or blockage in the arteries, the blood supply is reduced and thus the muscles become starved of oxygen, resulting in pain.
 
Some people may experience pain at rest, which is usually worse at night. This is because when the legs are elevated, the blood supply to the feet is reduced. The pain usually improves when the legs are lowered such as sitting or standing.

Risk Factors

There are certain conditions, which make you more prone to developing ulcers. These are:

• Smoking
• High blood pressure
• High fat diet
• Varicose veins
• Heart disease
• Anaemia
• Stroke
• Family history of heart disease, strokes or high cholesterol
• Cellulitus/phlebitis
• Varicose eczema
• Strokes
• Stress
• Being overweight
• Diabetes
• Multiple pregnancies
• Fracture or injuries
• Sitting or standing for long periods
• Rheumatoid arthritis

How the mixed aetiology leg ulcer is diagnosed?

Your healthcare professional will undertake a full holistic assessment of your condition, your medical history and lower limb examination. This will include a test to assess your circulation. This is called a Doppler ultrasound procedure (see separate leaflet). The Doppler will access the blood supply to your legs, allowing the healthcare professional to decide on the most appropriate treatment.

Treatment of mixed aetiology leg ulcers

Some patients will be treated with dressings. Others may use a combination of dressings and compression therapies. This means wearing a combination of bandages or stockings from toe to knee until the ulcer is healed. Once it has healed, you may be advised to wear compression stockings instead of the bandages to prevent the ulcer from coming back.

You may need treatment of the underlying disease either arterial or venous, your healthcare professional will refer you if required.

It may not always be possible to continue your compression therapy whilst in hospital. A suitable dressing will be applied until the compression can be recommenced. During your time in hospital, please try to rest and elevate your legs to help with the healing process.

Compression bandaging

This is the most important part of the treatment. The aim is to reverse the congestion caused by the damaged veins and to aid healing of the ulcer. The most common method is the application of between two and three layers of bandaging over the dressings. When the bandages are applied, the pressure is highest at the ankle and gradually becomes lower at the knee. The bandages are usually applied weekly unless the wound requires more regular dressing changes (see separate leaflet on compression bandaging).

Compression hosiery

A compression stocking over the dressing is sometimes used as an alternative to bandaging, however, is not our first line choice.
We may recommend compression hosiery at Class 2 (20mmHG) for patients who want to self-manage.

What can I do to help my ulcers heal?

A combination of the following is needed:

1. Elevate your legs for at least 30 minutes 3-4 times a day for example on a reclining chair, lying on the bed or using a foot stool. Try to raise your legs higher than your hips to help gravity pull the blood and fluid in the right direction, towards your heart, thereby reducing any swelling.
2. When not resting, try to keep as active as you can within your own limitations. Walking improves your circulation, and increasing the distance helps the formation of new blood vessels, which carry blood around the blockage (collateral circulation). Many people notice some improvement in the cramp like pain on walking as the collateral circulation opens up. Do not stand in one position for long periods of time. Discuss your exercises with your healthcare professional.
3. Stop smoking – if you are still smoking please stop. Smoking increases the narrowing of the arteries. If you stop smoking this process is slowed down. There are a number of support groups, so please ask your doctor or healthcare professional for advice.
4. Cut down on fatty foods and eat plenty of proteins such as fish and eggs, together with plenty of fresh fruit and vegetables. Some ulcers may need additional vitamins and minerals to help them heal. Try to maintain your weight, as being overweight puts extra strain on your veins.
5. Drink plenty of fluids during the day, unless advised otherwise by your doctor.
6. Take care of your feet – look out for any new changes in colour or new ulcers. If you are unable to do so yourself, ask a friend or use a mirror. Your toe nails should be cut on a regular basis. Do so with care, ensuring that you do not damage your skin. Seek help from a podiatrist/chiropodist.
7. Take care not to bang your legs as many ulcers start following an injury.
8. Make sure you do regular foot and ankle exercises (see leaflet).
9. Skin temperature – too much heat can damage your skin. Avoid hot baths, hot water bottles or sitting too close to the fire. Wear thick socks or slippers instead .
10. Footwear – make sure your shoes are comfortable and fit you correctly. Shoes which are too tight or rub can cause ulcers. Do not walk bare foot.

Do not:

1. Wear tight socks, shoes or corsets as they may restrict your circulation.
2. Sit with your legs crossed as this can slow or stop the circulation in your legs.

How long will it take to heal?

This is a difficult question. Ulcers take a long time to heal; it may be weeks for some people and months for others. The key to success is keeping to your healthcare professional’s advice and instructions. Do not be tempted to change your treatment.

Keeping your ulcer healed

Leg ulcers commonly do reoccur after being healed. To prevent this from happening:

1. You may be fitted with a pair of compression stockings by your healthcare professional.
2. Wear your stockings. They must be worn during the day time and maybe taken off at night (please consult with your healthcare professional.
3. Continue with foot and ankle exercises/leg elevation.
4. Try to avoid any injuries to your legs because a slight knock can cause a new ulcer.
5. Look out for signs which may indicate you are developing a new ulcer.
6. Attend your outpatient’s appointment clinics regularly as it is important to be monitored.
7. Continue to not smoke.

Further Advice

If you have any concerns or think you may be developing a new ulcer contact your healthcare professional immediately on:

Telephone Numbers for each service:
Telephone: ................................................................................
Single point of access number: ................................................
Locality: ....................................................................................

The Northern Care Alliance NHS Group
Oldham Care Organisation
Vascular Service Clinic:
Telephone:

Salford Leg Ulcer Services
Salford Care Organisation
Stott Lane Salford, Manchester, M6 8HD
Email: salfordtissue.viability@nca.nhs.uk
Tel: 0161 206 1700 - Community
Tel: 0161 206 2113 - Acute
Fax: 0161 206 2654