Arterial Ulcers vs. Venous Ulcers
by Dr. Aaron Fritts MD | December 2019
Arterial ulcers are caused by underlying peripheral artery disease, while venous ulcers are caused by venous insufficiency. Though both conditions can result in visible tissue damage, they’re very different in why they occur, how they present, and how they’re best treated. Vascular Specialist Dr. Aaron Fritts provides a side-by-side comparison of arterial ulcers vs. venous ulcers to help you better understand the subtleties of vascular disease.
In This Article:
- What causes arterial and venous ulcers
- How to distinguish arterial ulcers from venous ulcers using visual cues
- Treatment options for arterial venous ulcers
- Who to see about your vascular ulcer
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 heal your ulcers.
What Causes Arterial vs. Venous Ulcers?
Why Do Arterial Ulcers Occur?
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.  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. 
Why Do Venous Ulcers Occur?
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.  In about a quarter of individuals, both arterial and venous disease processes are present, adding to the complexity of management.
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How to Distinguish Arterial vs. Venous Ulcers
Visual Signs of Arterial Ulcers
Patients with artery disease often present with aching pain that is worsened by activity and relieved with rest.  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.
Visual Signs of Venous Ulcers
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.  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.  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.
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Treatment Options for Arterial vs. Venous Ulcers
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. 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. 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. 
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]
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.  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 Care in Dallas, TX
At IVC, 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.
IVC is fully-equipped to diagnose, image, and treat vascular conditions, and we have a strong reputation for compassionate, patient-centered care. Give us a call today to schedule your visit!
About The Author
Dr. Aaron Fritts is a practicing Vascular and Interventional Radiologist in Dallas, TX. Dr. Fritts has found passion in providing care for individuals suffering from debilitating vascular conditions. Outside of the clinic, Dr. Fritts works to educate patients and colleagues about vascular conditions and innovative treatment approaches. Because of his continued commitment to high quality care, Dr. Fritts was recently selected as a SuperDoctors Rising Star and has been voted one of D-Magazine’s best doctors in Dallas.
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 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.
 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.
 Agale SV. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers. 2013;2013:1-9.
 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.
 Conte SM, Vale PR. Peripheral Arterial Disease. Heart, Lung and Circulation. 2018;27(4):427-432.
 Shu J, Santulli G. Update on peripheral artery disease: Epidemiology and evidence-based facts. Atherosclerosis. 2018;275:379-381.
 Eberhardt RT, Raffetto JD. Chronic Venous Insufficiency. Circulation. 2014;130(4):333-346. doi:10.1161/CIRCULATIONAHA.113.006898
 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.
 Salcrido, R. C. Arterial vs Venous Ulcers: Diagnosis and Treatment: Advances in Skin & Wound Care. 2001;14(3):146-147.
 Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006;332(7537):347-350.
 Dean SM. Cutaneous Manifestations of Chronic Vascular Disease. Progress in Cardiovascular Diseases. 2018;60(6):567-579.
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