Successful Pharmacologic Treatment of Lower Extremity Ulcerations in 5 Patients With Chronic Critical Limb Ischemia

Steven M. Dean, DO, Patrick S. Vaccaro, MD


J Am Board Fam Med. 2002;15(1) 

In This Article

Case 2

A 58-year-old woman with type 2 diabetes mellitus, short-distance bilateral calf claudication, peripheral neuropathy, and current long-standing tobacco use (1 pack per day for 40 years) was seen for evaluation of a large left calf ulceration. Six weeks earlier, a bulla spontaneously developed that the patient debrided with hair scissors. Subsequently, a large, moderately painful ulcer evolved, which failed to improve despite treatment that included weekly debridement and oral and topical antibiotics.

The physical examination was remarkable for a 15 x 6 cm left calf ulceration with a base composed of an admixture of granulation tissue, moderate brin, and partial necrosis. The left femoral pulse was normal, but the popliteal, posterior tibial, and dorsalis pedis pulses were not palpable.

The left ankle-brachial index measured 0.48 with an ankle systolic pressure of 73 mm Hg. The ankle-brachial index was probably falsely elevated as a result of partially calcified vessels, as the arterial Doppler waveforms from the left popliteal, posterior tibial, and dorsalis pedis arteries were severely monophasic.

The patient adamantly refused to undergo arteriography and invasive intervention. Four more weeks of oral and topical antibiotics, weekly debridement, and aspirin therapy resulted in minimal improvement. Consequently, cilostazol, 100 mg twice a day, was added. During the next 6 weeks, increasingly robust granulation tissue appeared within the ulcer base, and the margins began to contract. A skin substitute wound dressing (Apligraf) was placed to expedite healing. Twelve weeks later, the ulcer had healed. At her 6-month follow-up examination, the patient has remained free of ulceration.


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