Lower extremity wounds associated with mixed venous and arterial insufficiency and relevant differential diagnosis

Venous leg ulcers are the most common etiology of leg ulcers. In patients with venous leg ulcers, the reported incidence of concomitant arterial insufficiency ranges from 15% to 30%. A thorough history evaluation for risk factors as well as signs and symptoms of peripheral artery disease (PAD), and diligent physical examination that includes peripheral pulse exam is critical to identify concomitant decreases in arterial perfusion. Ankle brachial and toe brachial indices are the primary method for establishing the diagnosis of PAD. Patients diagnosed with a mixed arterial and venous ulcer should have modified treatment that includes reduced compression rating and revascularization depending on the severity of their arterial disease. When a wound is refractory to treatment despite optimal venous, arterial, and wound therapy, an investigation should be undertaken for less common etiologies, which are also included in the differential diagnosis, such as autoimmune, infectious, and neoplastic ulcers.