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 5

A 41-year-old man with end-stage renal disease and hypertension was evaluated for persistent painful ulcerations on the right first and fourth toes. He was neither diabetic nor a smoker, and his renal failure was presumed caused by chronic pyelonephritis and possibly hypertension. Three months earlier he developed spontaneous painful ulcerations on the right first and fourth toes. His discomfort was aggravated by elevation and partially relieved with dependency and narcotic medication. The ulcerations had progressed despite supportive care and oral antibiotics.

When examined, he had a palpably cool right distal forefoot and toes, with dependent rubor and pallor on elevation. A small necrotic crust was observed on the right distal hallux, and an irregular ischemic ulceration was noted on the proximal-dorsal right fourth toe (Figure 5A). The bilateral femoral and popliteal pulses were easily palpable, but the dorsalis pedis and posterior tibial pulses were absent.

(Case 5). A. Ischemic-appearing ulcerations on right first and fourth toes. B. After receiving cilostazol for 24 weeks, the ulcers finally healed.

Ankle-brachial indices were inaccurate as a result of calcified arteries and arterial Doppler-documented triphasic bilateral femoral and popliteal waveforms, with monophasic bilateral dorsalis pedis and posterior tibial waveforms. The bilateral transmetatarsal pulsed volume recording waveforms were severely dampened, and the hallux waveforms obtained after 5 minutes of external warming were at, a finding documenting critical ischemia at the level of the forefoot and toes.

Although revascularization was offered as a treatment option, the patient requested an initial conservative approach to his care. As a result, cilostazol, 100 mg twice a day, was begun. Subsequently, the ulcerations and attendant rest pain slowly resolved within a 24-week period (Figure 5B). At a 3-month follow-up examination, no new ulcerations were found.

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