Dry Gangrene Of The

A 52-year-old woman with type 2 diabetes mellitus diagnosed at the age of 42 years and being treated with sulfonylureas, was referred to the outpatient diabetic foot clinic

Figure 7.9 Digital subtraction ang-iography of the foot illustrated in Figures 7.7 and 7.8, showing severe multifocal stenosis of both iliac arteries and almost complete obstruction of both superficial femoral arteries

Figure 7.9 Digital subtraction ang-iography of the foot illustrated in Figures 7.7 and 7.8, showing severe multifocal stenosis of both iliac arteries and almost complete obstruction of both superficial femoral arteries

Diabetic Foot Exam Pulses

for dry gangrene of her right fourth toe. No other diabetic complications were reported. She denied intermittent claudication.

A minor painless trauma of the affected toe was reported 1 week previously and the toe became black 24 h later. Edema and redness of the forefoot was reported and she was treated with cotrimoxazole and clindamycin, and bed rest. Within a week the injury became smaller and dried out.

On examination, she had findings of peripheral neuropathy; the pulses in her foot arteries were diminished. The ankle brachial index was 0.5 on the right, and 0.6 on the left side.

The fourth toe was gangrenous and shrunken, and a neuro-ischemic ulcer was noted under the head of the third metatarsal. Scaling of the skin due to edema which had subsided was also observed and onychodys-trophy was present (Figure 7.12). Digital subtraction angiography revealed significant stenosis of both proximal iliac arteries, just after the celiac aortic bifurcation (Figure 7.13). Aortic stents were inserted at the sites of stenosis, by catheterization which was carried out by an experienced radiologist, and the foot circulation was thus restored (Figure 7.14).

An X-ray of her left foot revealed an unknown stress fracture in the proximal phalanx of her fifth toe (Figure 7.15). Osteoarthritis was also apparent in the first and fourth metatarsophalangeal joints.

Ten days after stent insertion the fourth toe was amputated under local anesthesia. No complications occurred postoperatively, and the wound healed completely.

Keywords: Dry gangrene; intravascular stent; stress fracture; revascularization; toe amputation

Collateral Circulation Diabetic Foot
Figure 7.10 Digital subtraction angiography of the foot illustrated in Figures 7.7-7.9, showing the popliteal arteries being supplied from extensive proximal collateral vessels. (Courtesy of C. Liapis)

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