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 4

A 70-year-old woman with type 2 diabetes mellitus, hypertension, and left hemiparesis was evaluated for a nonhealing left distal hallux ulceration. The patient resided in an extended-care facility and was wheelchair bound as a result of a right hemispheric stroke. Six months before her vascular evaluation, the patient traumatized the distal aspect of her hallux while transferring from her wheelchair. A subsequent ulcer ensued that failed to improve despite multiple topical treatments and several courses of oral antibiotics.

When examined, she had bilaterally cool feet with pronounced dependent rubor and pallor on elevation. An ulceration with a dry necrotic base was noted on the distal left hallux (Figure 3A). No gross signs of infections were observed. The femoral pulses were normal; however, the bilateral popliteal, dorsalis pedis, and posterior tibial pulses were absent.

(Case 4). A. Ischemic left hallux ulceration when first examined. B. Left hallux after only 7 weeks of therapy with cilostazol. The ulcer had closed completely.

A radiograph was negative for osteomyelitis of the distal phalanx. Ankle-brachial indices could not be obtained because the bilateral dorsalis pedis and posterior tibial Doppler signals were inaudible. A pulsed volume recording study documented multi-segmental occlusive disease, and the bilateral ankle waveforms were essentially at, a finding consistent with critical limb ischemia (Figure 4).

(Case 4). Noninvasive arterial study when first examined. Ankle brachial indices could not be obtained because bilateral dorsalis pedis and posterior tibial doppler signals were inaudible. A pulsed volume recording study documented severe, multisegmental occlusive disease, and essentially flat bilateral ankle waveforms were consistent with critical limb ischemia.

Neither percutaneous nor surgical interventions were ideal treatment options because the patient was not ambulatory and the ulceration involved a paretic extremity. She was therefore given cilostazol, 100 mg twice a day. After only 7 weeks of cilostazol therapy, the ulcer had healed (Figure 3B). The ulcer remained healed when she was seen at a 2-month follow up visit.

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