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Diabetic and ischemic foot ulcers are difficult to heal, and the mastering of numerous treatment methods is imperative to achieve healing. One of these methods is the fillet toe flap used to cover specific diabetic wounds of the forefoot associated with toe osteomyelitis. Instead of amputating the infected toe, phalanges are removed while keeping the viable surrounding soft tissue.A systematic review was performed searching electronic databases up to October 2019 to identify relevant articles reporting the outcomes of the fillet flap in forefoot ulcers of patients with diabetes or peripheral artery disease. All study designs were included. The healing rate was the primary outcome. Secondary outcomes were the time to heal, ulcer recurrence, and complication rates of such infection, partial necrosis, and total necrosis.The 8 studies that met the inclusion criteria were all case series or case reports, with a total of 28 patients including 29 flaps. The mean healing rate was 92.8% (2/29); in both cases, total necrosis was due to infection (7.2%). No ulcer recurrence or partial necrosis was noted.Though having limited indications, the fillet flap illustrates the full optimization of the available resources for wound coverage. The consistent presence of an axial vessel makes the fillet flap a reliable local flap to be used in specific circumstances where the loss of a toe is unavoidable. Further research is needed with large prospective controlled trials to support the findings of the review.Les ulcères diabétiques et ischémiques du pied sont difficiles à guérir. Il est impératif de maîtriser de multiples méthodes thérapeutiques pour qu’ils cicatrisent. Le lambeau en filet de l’orteil, utilisé pour couvrir des plaies diabétiques précises de l’avant-pied associées à l’ostéomyélite de l’orteil, fait partie de ces méthodes. Au lieu d’amputer l’orteil infecté, les phalanges sont retirées, mais les tissus mous viables avoisinants sont conservés.Les chercheurs ont effectué une analyse systématique des bases de données électroniques jusqu’en octobre 2019 pour extraire les articles appropriés sur les résultats des lambeaux en filet pour les ulcères de l’avant-pied des patients atteints du diabète ou d’une maladie artérielle périphérique. Toutes les méthodologies d’étude étaient incluses. Le taux de guérison était le résultat clinique primaire, et le temps de guérison, la récurrence des ulcères, le taux de complications de cette infection et, la nécrose partielle et totale, les résultats cliniques secondaires.Les huit études qui respectaient les critères d’inclusion étaient toutes des séries ou des rapports de cas, pour un total de 28 patients qui avaient reçu 29 lambeaux. Le taux de guérison moyen s’élevait à 92,8 % (deux sur 29). Dans les deux cas, la nécrose totale était causée par l’infection (7,2 %). Aucune récurrence d’ulcère ni nécrose partielle n’a été observée.Même si les indications sont limitées, le lambeau en filet fait appel à l’optimisation totale des ressources disponibles pour couvrir les plaies. Grâce à la présence continue d’un vaisseau axial, le lambeau en filet est un lambeau local fiable à utiliser dans des situations particulières, lorsqu’il est impossible d’éviter de perdre un orteil. Il faudra réaliser la présence d’importants essais prospectifs contrôlés pour soutenir les observations de l’analyse.

Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

Цель. Определение морфологических особенностей кожных ран стопы пациентов с нейроишемической формой синдрома диабетической стопы (СДС) с целью оптимизации тактики и методов хирургического лечения. Материал и методы. Произведено морфологическое исследование мягких тканей стопы 12 пациентов с гнойно-некротическими осложнениями нейроишемической формы СДС с использованием гистологических, гистохимических и морфометрических методик. Пациенты были разделены на 2 клинические группы. Первую группу составили 6 пациентов, у которых согласно клиническим, анамнестическим и инструментальным методам исследования преобладали ишемические изменения. Вторая группа 6 пациентов, у которых преобладали нейропатические изменения в тканях. Результаты. Выявлена неоднородность клинических, инструментальных и морфологических данных у пациентов с гнойно-некротическими осложнениями нейроишемической формы СДС. В наблюдениях первой группы трофические нарушения в стопе клинически представлены сухой гангреной. Морфологически выражены тяжелые циркуляторные расстройства, утолщение стенок артериол и капилляров с сужением их просвета. Изменения периферических нервных стволиков характеризовались либо слабо выраженной демиелинизацией, либо отсутствием признаков разрушения миелина. Во второй группе трофические нарушения в стопе клинически представлены инфицированными ранами, остеомиелитом, флегмоной мягких тканей. Гистологически определялся обширный некроз с наложениями фибрина и гнойного экссудата. Выявлено также уменьшение количества сосудов, утолщение их стенки и сужение просвета. Изменения периферических нервных стволиков характеризовались разрушением миелина вплоть до тотальной демиелинизации и полной дегенерации осевых цилиндров, местами наблюдалось полное выпадение нервных волокон. Заключение. Проведенное исследование позволило при схожести сосудистых нарушений (макрои микроангиопатия) в обеих клинических группах убедительно показать морфологические различия при преобладании ишемического или нейропатического компонента в нейроишемической форме СДС. Выявленные клинико-морфологические особенности проявлений нейроишемической формы СДС доказывают необходимость индивидуального похода к лечению пациентов с учетом преобладания тех или иных морфологических изменений.

A patient with ischemic ulcer in the foot underwent femoral to peroneal in situ bypass with severe calcific occlusive disease using tourniquet occlusion. Postoperative arteriogram showed patent bypass with small residual arteriovenous fistula with faint filling of the deep vein. Management of residual arteriovenous fistula is described.

Background and Aims: Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia. Material and Methods: This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V–VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days–183 months). Results: Limb salvage was at 30 days—92%, at 1 year—91%, and at 5 and 10 years—86%. Survival and amputation-free survival were at 30 days—93% and 86%, at 1 year—80% and 76%, at 5 years—51% and 48%, and at 10 years—21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days—97%, at 1 year—88%, at 5 years—72%, and at 10 years—66%. Conclusion: Hybrid outflow revascularization is an important tool in the vascular surgeon’s armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.

Objective A multidisciplinary approach is required to treat critical limb ischemia. We determined the poor prognostic factors of ischemic ulcer healing after optimal arterial revascularization, and assessed the efficacy of the medication therapy using cilostazol, which is a selective inhibitor of phosphodiesterase 3. Methods In this retrospective, single-center, cohort study, 129 limbs that underwent infrainguinal arterial revascularization for Rutherford class 5 critical limb ischemia were reviewed. The primary end point was the ulcer healing time after arterial revascularization. The secondary end point was the amputation-free survival rate. Results Of the 129 limbs, endovascular therapy was performed in 69 limbs, and surgical reconstructive procedures were performed in 60 limbs for initial therapy. Complete ulcer healing was achieved in 95 limbs (74%). The median ulcer healing time was 90 days. In multivariate analysis, no cilostazol use significantly inhibited ulcer healing ( p = 0.0114). A white blood cell count >10,000 ( p = 0.0185), a major defect after debridement ( p = 0.0215), and endovascular therapy ( p = 0.0308) were significant poor prognostic factors for ulcer healing. Additionally, ischemic heart disease ( p Conclusions Ulcer healing within 90 days after arterial revascularization is impaired by no cilostazol use, a white blood cell count >10,000, a major defect after debridement, and endovascular therapy. Furthermore, cilostazol improves amputation-free survival rate in patients with critical limb ischemia.

Exposición de un caso clínico de un paciente varón de 69 años que presentaba una dehiscencia de unos 5 cm tras una amputación transmetatarsiana debido a rechazo de un injerto cutáneo al sufrir una quemadura de tercer grado. Se realizó desbridamiento cortante de tejido desvitalizado y curas en ambiente húmedo con apósitos de hidrofibra con iones de plata; posteriormente, se realiza implantación de terapia de presión negativa hasta conseguir el tejido de granulación a nivel de piel. Finalmente, se utilizaron apósitos liofilizados de colágeno (Epiona®) para una completa cicatrización y epitelización. Se prescribe zapato ortopédico, ortesis con relleno de la zona amputada e hidratación. Exposure of a clinical case of a 69-year-old male patient who presented a dehiscence of about 5 cm after a transmetatarian amputation due to rejection of a skin graft when suffering a third degree burn. Cutting debridement of devitalized tissue and cures in humid environment were performed with hydrofiber dressings with silver ions; subsequently, negative pressure therapy is implanted until the granulation tissue is obtained at the skin level. Finally, lyophilized collagen dressings (Epiona®) were used for complete healing and epithelization. Prescribed orthopedic shoe, orthosis with filling of the amputated area and hydration. Enfermería

Chronic wound is associated with many health comorbidities. It is essential for the clinicians to understand factors that contribute to its development and the delayed healing. Effective healing requires wound bed preparation, wound debridement, use of appropriate dressing materials, and, for some, the use of various modalities such as ultrasound, negative pressure wound therapy, and electrical stimulation.

Objectives: Analyze the influence of the collateral distal vessels on ischemic ulcer healing and limb salvage after successful distal procedures, according to an angiosome model. Methods: Retrospective analysis of 76 ischemic ulcers revascularized by surgical (n = 41) and endovascular (n = 35) distal procedures. All interventions were primary procedures with single outflow vessel that remained patent during follow-up. Ulcers were classified according to an angiography angiosome study as ‘‘direct revascularization’’ ([DR] n = 45), ‘‘indirect revascularization’’ ([IR] n = 31), and IR ‘‘through collaterals’’ ([IRc] n = 18). Healing rates and limb salvage were compared according to the type of revascularization. Results: Ulcer healing rate at 12 months was higher in DR than in IR (92% vs 73%, P = .008) but similar to IRc (92% vs 85%). Limb salvage at 24 months was higher in DR than in IR (93% vs 72%, P = .02) but similar to IRc (93% vs 88%). Conclusion: Ulcer blood flow restoration through collateral vessels may give similar results to those obtained through its specific source artery.

Objective: We investigated the effect of immersion of feet in CO2-enriched water for preventing expansion and formation of ischemic ulcer in critical limb ischemia of diabetic patients after surgical revascularization. Materials and methods: Eligible patients were allocated CO2 group (CO2 immersion plus standard care) or control group (standard care alone) and were followed up for 3 months after surgical revascularization. The end point is defined as an expansion of a target ulcer (more than 101% of original size) or the formation of new ulcers during the follow-up period. Results: Fifty-nine patients out of originally enrolled 66 patients with type II diabetes were included in intention-to-treat population. The cumulative prevention rate for ischemic ulcer after 3 months was 97.1% in the CO2 group, while, in the control group, it was 77.8%, i.e., significantly lower than the CO2 group (P = 0.012, log-rank test). The transcutaneous oxygen pressure increased significantly only in the CO2 group, from 56 ± 14 to 63 ± 15 mmHg (P < 0.01, Wilcoxon signed rank test), in 3 months. Conclusion: These results suggest that addition of CO2 immersion to standard care of critical limb ischemia in diabetic patients improves early postoperative outcome after vascular surgery.

Studies have shown that exogenous platelet-derived growth factor-BB (PDGF-BB) could accelerate the ulcer healing, but the lack of efficient growth factor delivery system limits its clinical application. Our previous work has demonstrated that the native human PDGF-BB was added a collagen-binding domain (CBD), TKKTLRT, to develop a collagen-based PDGF targeting delivery system. Here, we showed that this CBD-fused PDGF-BB (CBD-PDGF) could bind to collagen membrane efficiently. We used the rabbit dermal ischemic ulcer model to study the effects of CBD-PDGF loaded on collagen membranes. Results revealed that this system maintained a higher concentration and stronger bioactivity of PDGF-BB on the collagen membranes and promoted the re-epithelialization of dermal ulcer wounds, the collagen deposition, and the formation of capillary lumens within the newly formed tissue area. It demonstrated that collagen membranes loaded with collagen-targeting human PDGF-BB could effectively promote ulcer healing.

A úlcera hipertensiva de Martorell é úlcera isquêmica dolorosa de membro inferior, mais comum em mulheres, com dor desproporcional a seu tamanho e associada à hipertensão arterial sistêmica grave. É descrito um caso de homem negro, 56 anos, com hipertensão mal controlada de longa duração e lesão ulcerada extensa na panturrilha direita, cuja dor só foi aliviada com morfina, bloqueios peridurais e simpatectomia lombar. O diagnóstico baseou-se em hipertensão arterial, pulsos arteriais palpáveis, ausência de distúrbios venosos e dor intensa. O exame histopatológico de pele revelou alterações características, como espessamento da camada íntima da arteríola e estreitamento da luz. Martorell's hypertensive ulcer is a painful lower extremity ischemic ulcer, with female-to-male predominance and associated to severe systemic arterial hypertension. We describe a case of a 56 years-old black man with long standing and poorly controlled arterial hypertension who presented a large ulcer on the right calf, whose pain was improved with morphine, peridural blockages and lumbar sympathectomy. The diagnosis was based on systemic arterial hypertension, palpable arterial pulses of lower extremities, absence of venous insufficiency and presence of intense pain. Cutaneous histopathology revealed characteristic lesions in the arterioles, such as thickening of intimal layer and narrowing of the lumen.

Background: Many treatment modalities are available for the treatment of ischemic ulcers in Buerger's disease (thromboangiitis obliterans [TAO]). Objectives: The objective of the study was to evaluate the efficacy and clinical outcome of autologous platelet-rich plasma (PRP) for the treatment of ischemic ulcers in TAO patients. Methods: This prospective observational study was conducted on selected TAO patients who underwent autologous PRP treatment in surgery department of a teaching hospital in Central India. Diagnosis of TAO was made on clinical grounds and Color Doppler study. Autologous PRP was injected subcutaneously around the area of ulcer on day 0 and then on the 5th and 10th day. Results were noted on day 1, day 5, day 10, and on day 15. Outcome monitored was improvement in pain (using visual analog scale) and healing of ischemic ulcers. Results: All 14 patients were males, chronic smokers, and most of the patients were in the 4th decade of life. All had involvement of lower limbs; one had upper limb ischemia as well. All patients had ischemic ulcers. Pain relief, as measured with visual analog scale score, was good; most of the patients had 50% relief within 24 h of injecting PRP, which persisted/continued to improve on days 5, 10, and 15. Similarly, ulcer healing showed improvement on days 5, 10, and 15. Conclusions: PRP can provide efficient treatment for pain and healing of ischemic ulcers in TAO patients.

Coiling of the artery is a rare morphologic entity, most frequently found in the internal carotid arteries. Coiling of other arteries is rarely reported because it is usually asymptomatic. We report a case of 360 degrees coiling of the right external iliac artery found by color duplex scan and arteriography. The patient was a 72-year-old man who presented with a 2-month history of an ischemic ulcer on his right toe and a right ankle-brachial-pressure index (ABPI) of 0.0 and 0.4 on admission. We resected 7 cm of the affected artery and performed end-to-end reconstruction. After 2 months of follow-up, his ischemic ulcer had healed and the ABPI of the right foot was 0.0 and 0.8.

Between 1991 and 1995 the authors performed the arteriovenous fistula (AVF) procedure, which forms the first stage of staged arteriovenous reversal (AVR), in 6 patients (4 with Buerger's disease, 2 with atherosclerosis obliterans) with lower extremity arterial occlusive disease. The patients were all men with a mean age of forty-one years. The clinical indications for revascularization included rest pain and nonhealing ischemic ulcer. The results were disappointing: 4 patients with patent fistulas underwent major amputation, and 2 with occluded fistulas underwent toe amputation.

Objectives: The objective of this study was to evaluate the efficacy, safety, and clinical outcome of percutaneous chemical lumbar sympathectomy (PCLS) in Buerger's disease (thromboangiitis obliterans [TAO]). Design: This was a retrospective comparative study. Methods: TAO patients who underwent PCLS in surgery department of a teaching hospital in Central India. Diagnosis of TAO was made on clinical grounds and color Doppler study. PCLS was done under image guidance after amputation of gangrene or before if a clear line of demarcation was lacking. After PCLS, patients were followed up on next day and after 2, 4, 8, and 12 weeks. Outcome monitored were improvement in rest pain (using visual analog scale) and healing of ischemic ulcers. Results: All patients were males, chronic bidi smokers, mostly in the third decade of life. All had involvement of lower limbs either ischemic rest pain or ischemic ulcers or gangrene of toes/forefoot. A total of 167 PCLS (20 bilateral) were performed on 147 TAO patients from June 2008 to January 2016. Imaging modalities were computed tomography scan (n = 67), digital X-ray (n = 50), and C-arm fluoroscopy (n = 50). Success rate for chemical neurolysis was > 82%. Excellent long-lasting rest pain relief was obtained in > 80% patients. Ulcer healing was seen in majority of patients. Large number of limbs (103/167) had gangrene of toe/multiple toes/part of forefoot. Those with patent popliteal artery fared better. Conclusions: PCLS can provide safe and efficient treatment for rest pain and healing of ischemic ulcers in TAO.

This case report describes the use of a new medical device that utilizes vacuum-compression therapy (VCT) in the management of a 30-year-old female patient with severe arteriosclerosis and an associated nonhealing fasciotomy wound. Attempts were made to treat the patient with local care consisting of debridement and saline-moistened gauze dressings. Following a poor response to nonsurgical management, a skin graft was performed in an attempt to encourage more rapid healing. Infection and poor healing followed the graph, and only 40% of the graft remained viable after 12 days. Outpatient physical therapy management consisted of hydrotherapy and hydrocolloid dressings. This treatment resulted in minimal success until combined with VCT. The patient received hydrotherapy, VCT, and hydrocolloid dressings three times per week for 11 weeks. Wound healing occurred at an average rate of 0.64 cm2 per day, and the wound completely reepithelialized by the end of the eighth week of VCT therapy. Increased capillary filling is proposed as a primary factor in the improved healing.

A case of arteriosclerosis obliterans with ischemic ulcer treated by totally implanted arterial access system is described. The patient was a 96-year-old man with ischemic ulcer (Grade 4 of Fontaine's classification) in the right 2, 3, and 4th toes. Angiography revealed an obstruction of the popliteal artery and poor run off to the peripheral artery. Reconstruction by bypass grafting was not indicated and intravenous injection of LipoPGE1 was not effective. So a totally implanted arterial access system was used and LipoPGE1 was injected through the system repeatedly. Though the minimum amputation of the toe was required, perioperative peripheral circulation was sufficient and wound healing was satisfactory.

Limb-threatening ischemia (rest pain, ischemic ulcer, gangrene), in the presence of native autogenous vein.

Arterial pathology of the lower extremity is common in the elderly. It has been the author's experience that most arterial pathology affecting the foot is caused by peripheral arterial occlusive disease, emboli, or infection. One of the most important factors determining whether healing will take place is the adequacy of the arterial blood supply. It is essential that health care providers be able to recognize whether the patient's blood flow is sufficient to maintain tissue nutrition or heal an ischemic ulcer, whether signs or symptoms presented by the patient are a result of an arterial system disorder, and, if arterial blood flow is compromised, whether the patient should be referred to a specialist.

The management of the chronically ischemic leg with ulcer formation that is not suitable for either surgical or interventional treatment is still a matter of controversy. We describe three cases of ischemic ulcer treated with basic fibroblast growth factor spray. Ulcer healing was accelerated and complete epithelialization was achieved in all cases. Basic fibroblast growth factor spray is useful in the treatment of the ischemic ulcer in patients with arteriosclerosis obliterans, especially in high-risk surgical patients.

background. Diabetes accounts for over half of the lower extremity amputations in the United States. However, ulcers of the diabetic foot can often be treated successfully and amputations avoided. objective. To review treatment of diabetic foot ulcers. results. Physicians must recognize the critical clinical and diagnostic features of ischemic and neuropathic ulcers. Therapy is directed towards vascular repair in the ischemic ulcer and relief of weight bearing through casting and shoes with molded insoles in the neuropathic ulcer. Sound principles of wound care apply to all ulcers. conclusion. For successful preventive foot care patients and physicians need to understand how and why ulcers form and the rationale for the types of footwear and care necessary to prevent ulcers.

This chapter discusses the interrelationship of venous disorders with ischemia and other conditions. The term ischemia, in connection with an ulcer, can be used in two ways. It may refer to a local ischemia caused by microangiopathy in the fibrotic tissue surrounding a longstanding venous ulcer, a diabetic or rheumatoid ulcer, but more usually it is used to describe the overall reduction in the arterial supply to the distal part of a limb, commonly caused by arterial disease, especially atherosclerosis. An ischemic ulcer is due to an arterial insufficiency that reduces the arterial pressure in the distal part of the limb. An arterial ulcer does not develop unless the horizontal perfusion pressure is reduced below 60 mmHg and at this level, the pressure is inadequate to compete with any elevation of the foot. The bacteriology of the venous ulcer is also important although there is a tendency for some authorities to be dismissive over this. In the authors experience, the presence of a pathogen, especially Staphylococcus aureus , can be the cause of considerable pain in an ulcer and failure to respond to treatment. Certainly a range of harmless organisms is usual in the venous ulcer but unless it is looking in a healthy and settled state, culture is advised, with treatment by an appropriate antibiotic if a known pathogen is identified.

Since 1980, 498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index less than 0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure.

A double-blind multiclinic trial compared the efficacies of pyridinolcarba mate and inositol niacinate in the patients with the ischemic ulcer due to chronic arterial occlusion. A thrice-daily dose of 1.5 g of pyridinolcarba mate or 1.2 g of inositol niacinate was given at random to the patients during cold seasons, and the effectiveness of treatment was assessed mainly on the basis of the clinical course of the ischemic ulcer and the rest pain. The patients were classified into 4- and 6-week groups. Beneficial results were recorded in 16 of 32 cases (50.0%) of the 4-week pyridinol carbamate group, and in 24 of 42 cases (57.1%) of the 4-week inositol niacinate group. In the 6-week group favorable results were observed in 54 of 79 cases (68.4%) on pyridinolcarbamate, and in 36 of 74 cases (48.6%) on inositol niacinate. Although sympathectomy is currently indicated for these ischemic lesions, long-term treatment with pyridinolcarbamate is recommended on the basis of the finding that the 6-week treatment ap pears superior to the 4-week treatment and also to the 6-week treatment with inositol niacinate.

Forty patients with an ischemic ulcer of the lower extremity had peripheral vascular perfusion studies, performed with intra-arterial injections of aggregated technetium Tc 99m serum albumin microspheres (15mu to 30mu in diameter), in an attempt to develop an objective prognostic criterion for healing. The association between ulcer healing and the presence or absence of diabetes mellitus, palpable peripheral pulses, and patent trifurcation vessels on the arteriogram was reviewed and no association was noted. When, however, there was a relative hyperemia of the ulcer bed in comparison to the adjacent tissue of at least 3.5:1, as determined by counting the amount of radioactivity per unit area, 86% of patients went on to heal their ulcers. In those without this degree of hyperemia, only 11% were healed with conservative nonsurgical management. The results have shown that relative hyperemia of the ulcer bed is a clinically useful prognostic indicator in the patient with ischemic ulcer disease.

A 33-year-old man with a nonatherosclerotic vasculopathy of undetermined origin had progressive occlusive disease of the lower limb vessels. The resultant severe rest pain and ischemic ulceration of his foot were inoperable and unresponsive to conventional drug therapy. Treatment was begun with intra-arterially administered alprostadil (prostaglandin E1), a vasodilator and inhibitor of platelet aggregation. Although immediate benefit was equivocal, his rest pain had disappeared six weeks after infusion, and the ischemic ulcer almost healed completely. Blood flow studies showed increased flow to the feet, consistent with the subjective improvement. The beneficial effect of alprostadil suggests that further studies with this agent are warranted for patients with nonatherosclerotic vasculopathy. (JAMA1981;245:1846-1849)

To the Editor:— I refer to the article on gold-leaf treatment of ischemic skin ulcers ( 196 :693, 1966) and to the comment by Dr. Epstein ( 197 :299, 1966). Thirty years ago one of my elderly patients with an ischemic ulcer of the lower leg told me that she and her friends had treated this kind of an ulcer for many years by covering it with a lead sheet made by flattening Minie balls collected from the fields of Gettysburg. My patient had made a special trip to Gettysburg for the particular purpose of finding these leaden pellets, and I think she finally came to me only because she had exhausted her collection. Those from Gettysburg, she said, were considered to be the best, and she had frequently found that the Gettysburg Minie balls helped her friends when ordinary lead sheets had failed. She thought that this treatment of ulcers had