Nonhealing lower extremity ulcer

An 85-year-old woman with a history of tobacco use presents for hospitalization with nonhealing left lower extremity ulcer. Review of her records reveals several bouts of recurrent cellulitis dating back to 2018 (Figure 1) all of which resolve with antibiotics. The area of cellulitis is eventually complicated by bullous lesions (Figure 2), which develop into a nonhealing ulcer (Figure 3). Despite aggressive wound care and antibiotic therapy, lack of clinical improvement culminates in a biopsy suggestive of vascular insufficiency. Ankle-brachial index revealed a value of 0.4, consistent with severe peripheral arterial disease (PAD). Angiography revealed focal stenosis of the superficial femoral artery and chronic total occlusion of the proximal popliteal artery (Figure 4). Intravascular lithotripsy with angioplasty was performed with improved wound healing postprocedure. In the evaluation and treatment of skin and soft tissue infections (SSTI), underlying conditions should always be considered. PAD affects approximately 11% of the US population, with higher prevalence in older adults, and is associated with increased cardiovascular morbidity and mortality.1 Chronic limb-threatening ischemia (CLTI), a manifestation of PAD, is defined as ischemic pain in the foot while a person is at rest with pain lasting 2 or more weeks, nonhealing wounds, or gangrene that is attributable to objectively proven arterial occlusive disease.2 These patients may benefit from revascularization to promote wound healing and reduce the risk of recurrent SSTIs. Identifying and addressing underlying vascular pathology is essential for effective management and improved outcomes in patients with refractory SSTIs and nonhealing wounds. The authors declare no conflicts of interest.