Chronic Venous, Arterial, and Mixed Arterial–Venous Ulcers and Pressure Injuries: An Integrative Review of Etiology, Chronicity, Assessment, and Management

Chronic wounds constitute a major clinical and healthcare challenge because they are associated with prolonged treatment, recurrent tissue breakdown, pain, impaired mobility, reduced quality of life, and substantial use of professional and material resources. Although venous leg ulcers, arterial ulcers, mixed arterial–venous ulcers, and pressure injuries share several mechanisms of impaired repair, they arise from different causal pathways and require distinct diagnostic and therapeutic strategies. This integrative narrative review critically synthesized evidence concerning etiology, biological mechanisms of chronicity, clinical assessment, differential diagnosis, foundational treatment, local wound management, adjunctive interventions, nursing practice, digital technologies, and recurrence prevention across these four wound categories. A structured literature search incorporated clinical guidelines, systematic reviews, clinical trials, observational investigations, qualitative studies, methodological reports, and authoritative institutional documents. Evidence was organized through thematic and comparative synthesis because heterogeneity in wound definitions, populations, interventions, and outcome measures precluded a unified quantitative analysis. Persistent inflammation, hypoxia, oxidative imbalance, extracellular-matrix degradation, microbial persistence, cellular dysfunction, and senescence were identified as shared barriers to repair. Nevertheless, successful management depended primarily on control of the underlying cause: compression and venous intervention for appropriately assessed venous ulcers, objective perfusion assessment and revascularization when indicated for arterial ulcers, individualized compression with vascular surveillance for mixed ulcers, and sustained pressure redistribution for pressure injuries. Debridement, infection management, exudate control, periwound protection, pain relief, nutritional assessment, nursing coordination, and person-centered education remained important across etiologies. Adjunctive biological, regenerative, oxygen-based, electrical, digital, and sensor-assisted interventions may benefit selected patients but should not replace etiology-directed foundational care. Durable outcomes require sustained closure, recurrence prevention, feasible treatment plans, coordinated follow-up, and evaluation of outcomes that are meaningful to patients and caregivers.