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

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

Disclosures

J Am Board Fam Med. 2002;15(1) 

In This Article

Case 3

An 87-year-old woman with a history of type 2 diabetes mellitus, short-distance bilateral calf claudication, and current long-standing tobacco use (1/2 to 1 pack per day for 60 years) came in for evaluation of a nonhealing painful ulceration on the left distal second toe. Her toe pain was aggravated by elevation and relieved when in a dependent position. The ulcer spontaneously appeared 1 month earlier and had not improved despite topical mupirocin and oral pentoxifylline. When examined, she had a palpably cool left foot with dependent rubor and pallor on elevation. A distal ulceration was found on the left second toe; its base was predominately composed of brin and minimal granulation tissue. No exposed or palpable bone was observed. The left femoral pulse was normal, but the popliteal, dorsalis pedis, and posterior tibial pulses were absent.

The left ankle-brachial index measured 0.47, with an ankle systolic pressure of 74 mm Hg; however, this value was falsely elevated as the arterial Doppler waveforms from the posterior tibial and dorsalis pedis arteries were severely monophasic (nearly at), a finding consistent with severe large-vessel ischemia. The left first and second toe plethysmographic waveforms obtained after 5 minutes of external warming were essentially at (≤ 2mm), indicating attendant critical small-vessel ischemia.

Invasive intervention was not an ideal treatment option because of her advanced age and comorbid disease. Cilostazol was started at a dose of 100 mg twice a day. After 17 weeks of cilostazol therapy, the ulcer had healed, and her ischemic rest pain had resolved. At a 3-month follow-up visit, no recurrent ulcerations had developed.

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