Arterial Ulcers

Arterial insufficiency ulcers, also referred to as ischemic ulcers, are chronic wounds resulting from inadequate perfusion due to peripheral arterial disease (PAD) or chronic limb-threatening ischemia (CLTI). These wounds are associated with high rates of infection, limb loss, and mortality. 

Risk Factors

Arterial ulcers reflect systemic vascular pathology and share risk factors with PAD and atherosclerosis:¹ Smoking remains the most potent modifiable risk factor, accelerating atherosclerosis and impairing angiogenesis.^1,2 As a separate identified risk factor, diabetes mellitus contributes via endothelial dysfunction, neuropathy, and impaired wound healing.¹ Conditions such as hypertension and dyslipidemia exacerbate atherosclerotic burden.¹ And lastly, chronic kidney disease can increase arterial calcification and vessel stiffness, complicating diagnosis and management.¹

Symptoms and Clinical Presentation

• Arterial ulcers typically appear on the distal lower extremities (toes, heels, lateral malleoli). Classic features include:
• “Punched-out” morphology with well-demarcated borders.³
• Pale, necrotic wound base, often dry with minimal granulation tissue.³
• Severe pain that often occurs at night.
• Cool, shiny, hairless skin and absent or diminished distal pulses on exam.
• In advanced cases, gangrene or systemic infection may develop.

Untreated arterial ulcers can progress as the arterial disease progresses to CLTI, characterized by rest pain, nonhealing wounds, or tissue loss.

Etiology and Pathophysiology

The underlying mechanism of arterial ulcers is chronic ischemia caused by:¹

• Macrovascular disease (atherosclerotic occlusion, thromboembolic disease, vasculitis)
• Microvascular dysfunction (diabetes-related endothelial injury and impaired angiogenesis)
• Biomechanical stress (pressure, shear, and trauma to poorly perfused tissue)

Perfusion thresholds predict ulcer risk. Ankle-brachial index (ABI) <0.9 indicates PAD. ABI values <0.5, transcutaneous oxygen pressure (TcPO₂) <30 mmHg, or toe pressures <30 mmHg are strongly associated with ulceration and poor healing.¹

Treatment

Vascular assessment and revascularization. ABI, toe-brachial index, TcPO₂, and duplex ultrasound remain first-line. Imaging with CT angiography, MR angiography, or digital subtraction angiography defines anatomy and guides revascularization. Open bypass and endovascular therapy are complementary. 

BEST-CLI trial data show the incidence of a major adverse limb event or death was significantly lower for bypass surgery than for endovascular intervention in patients with adequate saphenous vein conduits.⁴ The BASIL-2 trial, however, noted participants receiving vein bypass–first revascularization strategy were more than one third more likely than receiving best endovascular treatment (BET) first revascularization to die from any cause during a median follow-up of 40 months.⁵ 

Local wound care. Wound bed preparation can follow the TIME framework (Tissue, Inflammation/infection, Moisture balance, Edge advancement). Clinicians may choose surgical or enzymatic debridement once perfusion is adequate. Larval therapy and advanced enzymatic agents may be useful for biofilm disruption. Targeted dressing and topical agent selection should address any antimicrobial needs, moisture-control, or other wound-specific features. 

Adjuvant Therapies

Below are just a few of the adjunct treatment options that one may consider in arterial ulcers:

Negative pressure wound therapy (NPWT). Promising results in ischemic ulcers post-angioplasty; improved 6-month healing rates in randomized studies.⁶

Hyperbaric oxygen therapy (HBOT). Meta-analyses confirm HBOT reduces major amputations in diabetic ischemic ulcers, though effects on long-term healing are less consistent.¹

Intermittent pneumatic compression (IPC). Enhances blood flow and reduces amputation rates in patients unsuitable for revascularization.¹

Pain Management

In patients with arterial ulcers pain is common and undertreated. A ladder approach should involve topical and non-opioid analgesics, then opioids if necessary.¹ Neuropathic pain agents such as gabapentinoids, tricyclic antidepressants, and SNRIs, may be indicated.¹ Peripheral nerve blocks or spinal cord stimulation may be considered for refractory cases, with evidence supporting both pain reduction and improved perfusion.¹

Conclusion

Arterial ulcers signify advanced ischemia and carry grave prognostic implications. Optimal outcomes require early recognition of risk factors, thorough vascular assessment, and timely revascularization. Wound care should follow the TIME principles, incorporating debridement, infection control, and moisture optimization. Adjuvant therapies may offer adjunctive benefit, particularly when revascularization is limited or delayed. Preventive efforts centered on risk factor control and patient education remain critical. Multidisciplinary, evidence-based strategies are the cornerstone of improving survival and limb salvage in patients with arterial ulcers.

References 
1. Federman DG, Dardik A, Shapshak D, et al. Wound Healing Society 2023 update on guidelines for arterial ulcers. Wound Repair Regen. 2024;32(5):619-629. doi:10.1111/wrr.13204
2. Wang W, Zhao T, Geng K, Yuan G, Chen Y, Xu Y. Smoking and the pathophysiology of peripheral artery disease. Front Cardiovasc Med. 2021 Aug 27;8:704106. doi: 10.3389/fcvm.2021.704106. PMID: 34513948; PMCID: PMC8429807.
3. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006;332(7537):347-350. doi:10.1136/bmj.332.7537.347
4. Farber A, Menard MT, Conte MS, et al; BEST-CLI Investigators. Surgery or endovascular therapy for chronic limb-threatening ischemia. N Engl J Med. 2022;387(25):2305-2316. doi:10.1056/NEJMoa2212540
5. Bradbury AW, Hall J, Moakes CA, et al. Editor's Choice - Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 Trial: Analysis of the Timing and Causes of Death in Participants Randomised to an Infrapopliteal Vein Bypass or Best Endovascular Treatment First Revascularisation Strategy. Eur J Vasc Endovasc Surg. 2025;69(1):102-107. doi:10.1016/j.ejvs.2024.07.029
6. Kim K, Lim X, Hong Q, et al. Use of home negative pressure wound therapy in peripheral artery disease and diabetic limb salvage. Int Wound J. 2020;17(3):531-539. doi:10.1111/iwj.13307