Cases Of Peripheral Vascular Disease Research Articles

Abstract No. : ABS2262: Ultrasound guided continuous stellate ganglion block in peripheral vascular disease of upper limb - A case series

Background and Aims:Stellate ganglion block relieves pain and improves perfusion in peripheral vascular disease(PVD) of upper limbs. Single shot stellate ganglion block often provides only short-term relief and repeated blocks are associated with tissue or neural damage and infections. Non-availability/affordability limits the use of thermal radiofrequency nerve ablation of the stellate ganglion.We report our experience of managing 46 cases of PVD of upper limb with continuous stellate ganglion block(CSGB).Methods:Six cases of PVD of left upper limb who presented with severe ischemic neuropathic pain and blackish discoloration of fingers were treated with ultrasound guided CSGB with infusion of 0.125% of bupivacaine at 5ml per hour for 5 days. All patients were assessed for intensity of pain using numerical rating scale (NRS), change of colour and peripheral pulsations before the procedure and 2, 4, 12 and 24 weeks after the procedure.Results:All the patients reported significant reduction in NRS scores, improvement in skin colour, healing of gangrenous lesions and return of peripheral pulsations at follow up visits.Conclusion:Continuous catheter infusion not only provides more sustained pain relief and emerges as a cost effective option in improving perfusion and aid wound healing.

Vascular Effects of Pseudoxanthoma Elasticum

Background: Pseudoxanthoma elasticum (PXE) is a rare hereditary disease caused by mutations in the ABCC6 gene, characterized by ectopic calcification of connective tissue throughout the body. Vascular conditions associated with PXE have been well-documented in the literature, but to our knowledge, analysis of the myriad of PXE case reports with associated vascular diseases in addition to larger cohort studies, has not been undertaken.
 Objective: To review existing literature reporting peripheral vascular disease (PVD), cardiovascular disease (CVD), cerebrovascular disease (CeVD), hypertension, and carotid rete mirabile (CRM) in PXE patients as of June 2021.
 Methods: A search of the PubMed database using the key words “pseudoxanthoma elasticum” and “vascular” was performed.
 Results: A total of 345 cases of PVD, 97 cases of CVD, and 123 case of CeVD were reported. Additionally, 88 cases of hypertension and 5 cases of CRM were reported.
 Conclusions: PXE patients are at risk of developing serious vascular conditions, particularly peripheral vascular disease. This condition also appears to have some connection to carotid rete mirabile, which is extremely rare in humans. Further research should be conducted to analyze the connection between PXE and CRM in order to better understand and treat both conditions.

2271-PUB: Rate of Diabetes Complications during the Initial 6 Months of the First Large-Scale Longitudinal Nationwide Study on Management and Real-World Outcomes of Diabetes in India (LANDMARC)

LANDMARC (CTRI/2017/05/008452) aims to evaluate the development and progression of diabetes complications over 3 years in Indian participants with T2D. Rate of diabetes complications was compared from baseline to 6 months (visit 2 [V2]) using McNemar’s test and Chi square test (when complications were stratified in subgroups). There was an increase in the rate of microvascular complications by V2 (Table). Microvascular complications were reported more commonly in participants with A1C≥7% than A1C<7%, with BMI≥23 kg/m2 than BMI<23 kg/m2, and in those with than without cardiovascular (CV) risk factors (Table). In case of macrovascular complications, 7 new cases of peripheral vascular disease, 2 new cases each of MI, stroke and ACS, but no new case of heart failure or unstable angina were reported at V2. Notably, neuropathy was the most common complication at 6 months. The real-world data on complications in LANDMARC may help in understanding disease progression and offer insights on treatment adjustments. Disclosure R. Ghosh: Employee; Self; Sanofi. A.K. Das: Advisory Panel; Self; Novo Nordisk A/S, Sanofi. S. Joshi: Advisory Panel; Self; Novo Nordisk A/S, Roche Pharma, Sanofi. A. Mithal: Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Johnson & Johnson, Lilly Diabetes, Novo Nordisk A/S. K. Kumar: None. S. Kalra: Advisory Panel; Self; Eli Lilly and Company. Speaker’s Bureau; Self; Novo Nordisk A/S, Sanofi-Aventis. A. Unnikrishnan: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi. Speaker’s Bureau; Self; Eli Lilly and Company, Ipca Laboratories, Merck Sharp & Dohme Corp., Novartis AG. H. Thacker: None. B. Sethi: None. S. Mohanasundaram: Employee; Self; Sanofi. S.K. Menon: None. A. Nair: Employee; Self; Sanofi. N. Rais: None. S. Wangnoo: None. S. Chowdhury: Advisory Panel; Self; Novo Nordisk A/S. A.H. Zargar: None. Funding Sanofi India Limited

Prolonged Peripheral Hypoperfusion Promotes Neuroprotection in Ischemic Stroke.

ObjectivesSublethal, transient occlusion of peripheral vessels, called remote ischemic preconditioning (RIPC), induces a neuroprotective state against brain infarction. Recent studies suggest chronic hypoperfusion in patients with peripheral vascular disease (PVD) has analogous effects. We hypothesized a positive correlation between the severity of chronic hypoperfusion and the extent of neuroprotection. To determine if this correlation exists, we compared stroke volumes and clinical measures of modified ranking scale (mRS) and National Institute of Health Stroke Scale (NIHSS) between cases with and without PVD, subgrouping PVD cases by ankle-brachial-index (ABI) values.Patients and methodsCases of ischemic stroke with and without PVD were sampled retrospectively from a local institutional data base. Charts were manually reviewed for demographics (age, sex, ethnicity), comorbidities (diabetes, hypertension, hyperlipidemia, coronary artery disease, smoking, and stroke history), clinical measures (admission NIHSS, prior mRS, three-month mRS, and survival) and stroke volumes in each case. Those diagnosed with PVD and ABI indicating active disease were grouped as PVD cases; those not diagnosed with PVD or having ABI indicating absence of disease were used as controls. PVD cases were subgrouped by disease severity per ABI values: mild (ABI 0.8-0.9), moderate (ABI 0.5-0.9) and severe (ABI < 0.5). Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted cox proportional hazards models were used to estimate associations between survival and PVD.ResultsA total of 105 patients, 50 PVD cases and 55 controls, were collected. Mean age was 72.54 years, 51.4% were males and 48.6% females, and 94% were Caucasian. There were 17 mild, 22 moderate, and 11 severe cases of PVD. A higher incidence of comorbidities was present in PVD cases. The mean admission NIHSS was 4.44 and did not differ significantly between groups. Stroke volumes were significantly lower (p = .021) in PVD cases (4.39 ± 8.97 ml) compared to controls (19.33 ± 44.31 ml). There was also a significant difference (p = .04) between volumes of mild (3.86 ± 5.47 ml) and severe (0.63 ± 0.76 ml) PVD cases. There were significant differences (p = .012) in the incidence of good outcomes in moderate to severe PVD cases (100%) compared to controls (83.3%). There was no difference in survival between groups (p = .538).ConclusionIncreasing degrees of hypoperfusion related to PVD have a potential neuroprotective effect in acute ischemic stroke quantified by lower stroke volumes and better clinical outcomes at three months as seen in other preclinical models of RIPC.

Correlation of Ankle Brachial Index with Peripheral Vascular Disease in Type 2 Diabetes Mellitus

Objective : The aim of this study was to correlate ankle brachial index (ABI) with peripheral vascular disease (PVD) in type 2 diabetes mellitus . Material and methods : This was a hospital based interdisciplinary prospective study. A total of 100 patients in the age group of 30 to 80 years having peripheral vascular disease with predefined inclusion criteria were included in the study. Patients with other causes of raised blood sugar or peripheral vascular disease were excluded by relevant investigations. Ankle Brachial Index (ABI) was calculated using sphygmomanometer, and Colour Doppler Ultrasound (CDU) was used to diagnose PVD. Both the ABI method and the CDU method were compared for detecting PVD. Results : In our study, mean age was 60.04 ± 5.03 years, mean body mass index was 27.10 ± 2.67 kg/m2 and mean duration of diabetes was 7.75 ± 1.50 years. Among the 68 diagnosed cases of PVD on CDU, 70.6% cases were detected to have PVD by the ABI method (true positive) whereas 20 (29.4%) cases remained undiagnosed when ABI alone was used for the diagnosis (false negative). Conversely, among 51 diagnosed cases of PVD by ABI method 5.9% cases were found to be normal on CDU (false positive). The ABI method was found to have specificity of 88.5% but the sensitivity was only 70.6%. Conclusion: ABI has a very high specificity but the sensitivity is low compared to colour Doppler ultrasound. Therefore, if ABI is abnormal, the diagnosis of PVD is almost certain but in symptomatic cases with normal ABI; colour Doppler should be performed to exclude the PVD. Keywords : Ankle Brachial Index, peripheral vascular disease, Colour Doppler Ultrasound, type 2 diabetes mellitus. DOI : 10.7176/JMPB/57-02 Publication date : July 31 st 2019

Clinical Study of Peripheral Arterial Disease in Lower Limbs

Background: Peripheral arterial disease (PAD) is part of a global vascular problem of diffuse atherosclerosis. PAD patients die mostly of cardiac and cerebrovascular-related events and much less frequently due to obstructive disease of the lower extremities. Aggressive risk factors modification is needed to reduce cardiac mortality in PAD patients. Aim and objectives: To study the frequency of risk factors in peripheral vascular disease, To study the clinical presentations of peripheral vascular disease, To study the imaging modalities in assessment of peripheral vascular disease, To study the responsiveness of medical therapy for this disorder. Results: It is a prospective clinical study of 50 cases of peripheral vascular disease, who are presenting to Department of Surgery, Dr.PSIMS & RF over a period of 2 years from October’2013 to September’ 2015, which included 50 admitted cases in different surgical units picked randomly and study was conducted. Atherosclerosis accounted for 80% of these cases and was found to be the commonest cause of lower limb ischemia in this region. TAO accounted for 20% and was the next common cause of lower limb ischemia. 82% cases were associated with diabetes mellitus. Conclusion: Peripheral vascular disease is a common surgical problem with most of the population being males and among them mainly involving the smokers. Presentation was mainly claudication pain and minor percent presented with rest pain. Arterial Doppler is a specific investigation for peripheral vascular disease Patients if present early in the disease process medical line of management like exercise, antiplatelet medication, cholesterol lowering medication and drugs like Cilostazol, pentoxiphylline have been prescribed and followed. If limb salvage was planned minor procedures like debridement, ray amputation are sufficient. If they present late in the disease process Major procedures like below knee amputation and above knee

Comorbid anxiety disorders alter the association between cardiovascular diseases and depression: the German National Health Interview and Examination Survey

This study aims to examine whether specific anxiety disorder comorbidity alters the purported association between depression and specific cardiovascular diseases (CVDs). In 4,181 representative German participants of the general population, 12-month prevalence of psychiatric disorders was assessed through the Composite International Diagnostic Interview and CVDs by physician verified diagnosis. Adjusting for conventional risk factors logistic regression analyzed the association between CVDs (peripheral vascular disease (PVD), hypertension, cerebrovascular disease and heart disease) and combinations of comorbidity between depression and anxiety disorder types (panic disorder, specific phobia, social phobia and generalized anxiety). There were 770 cases of hypertension (18.4 %), 763 cases of cerebrovascular disease (18.2 %), 748 cases of PVD (17.9 %), and 1,087 cases of CVD (26.0 %). In adjusted analyses phobia comorbid with depression was associated with cerebrovascular disease (odds ratio (OR) 1.61; 95 % confidence interval (CI) 1.04-2.50) as was panic disorder (OR 2.89; 95 % CI 1.47-5.69). PVD was significantly associated with panic disorder (adjusted OR 2.97; 95 % CI 1.55-5.69). Panic disorder was associated with CVDs (adjusted OR 2.28; 95 % CI 1.09-4.77) as was phobia (adjusted OR 1.35; 95 % CI 1.04-1.78). Classification of anxiety and depression according to comorbidity groups showed discrete effects for panic disorder and specific phobia with CVDs, independent from covariates and depression.

Spinal cord stimulators in an outpatient interventional neuroradiology practice

PurposeSpinal cord stimulation is a known modality for the treatment of chronic back and neck pain. Traditionally, spine surgeons and pain physicians perform the procedures. We report our experience in...

Endoscopic Single-Port Lumbar Sympathectomy: Preliminary Experience

Introduction: Retroperitoneoscopic lumbar sympathectomy was first described in 1973.1 For its minimal invasiveness, the technique was then widely accepted for various conditions like plantar hyperhydrosis, nonreconstructive peripheral vascular disease (PVD), and reflex sympathetic dystrophy.2–4 The novel technique endoscopic single-port surgery (laparoendoscopic single-site surgery [LESS]) has been performed in various operations that aim at performing laparoscopic surgery by consolidating all ports within a single skin incision. The most obvious advantage of LESS is its cosmetic outcome compared with conventional laparoscopic procedure (one port vs. at least three ports). To date, the feasibility and safety of LESS lumbar sympathectomy have not been reported in the literature. Here, we report our preliminary experience in LESS lumbar sympathectomy. Materials and Methods: Between March 2010 and July 2010, four consecutive LESS lumbar sympathectomies were performed in two cases. Surgical indications were refractory nonreconstructable PVD and plantar hyperhidrosis. LESS lumbar sympathectomy was performed with a homemade single port created using an Alexis wound retractor through a 2-cm incision beneath the tip of 12th rib.5 Standard 5-mm 30° laparoscope and straight laparoscopic instruments were used for subsequent manipulation. The video includes a brief review of a patient with refractory nonreconstructable PVD that operated with the same technique. Results and Conclusions: The procedure was completed without multiport laparoscopic or open conversion. The mean operative time was 67 minutes (range 55–110). The histological analysis of the resected ganglions revealed ganglion cells and nerve tissues. The skin temperature of the sole of the foot increased immediately after ganglion resection. The case of hyperhidrosis had anhidrosis of both feet at 1 month of follow-up and the case of PVD had significant relive of pain postoperatively. The mean hospital stay was 2.5 days. There was no operation-related complication. The potential benefit of single-port surgery that could only be concluded in this study is its cosmetic effect. According to our unpublished randomized study, the average final scar length of three 5-mm trocars is 3 cm for a standard laparoscopic surgery. Thus, the cosmetic advantages of single-port surgery are not only reduced number of incisions but also the reduced final total scar length. However, further prospective study is warranted to provide the evidence concerning the clinical benefits of single-port surgery other than cosmetic effect. In conclusion, our preliminary experience revealed that endoscopic single-port lumbar sympathectomy is a safe, feasible, and reproducible procedure. Shiu-Dong Chung, M.D., Tin-Chou Li, M.D., and Ta-Chung Shen, M.D., contributed equally to this work. No competing financial interests exist for any of the authors. Runtime of video: 7 mins 8 secs

Efficacy of stellate ganglion block with an adjuvant ketamine for peripheral vascular disease of the upper limbs

Stellate ganglion block (STGB) is commonly indicated in painful conditions like reflex sympathetic dystrophy, malignancies of head and neck, Reynaud’s disease and vascular insufficiency of the upper limbs. The sympathetic blockade helps to relieve pain and ischaemia. Diagnostic STGB is usually performed with local anaesthetics followed by therapeutic blockade with steroids, neurolytic agents or radiofrequency ablation of ganglion. There is increasing popularity and evidence for the use of adjuvants like opioid, clonidine and N Methyl d Aspartate (NMDA) receptor antagonist – ketamine – for the regional and neuroaxial blocks. The action of ketamine with sympatholytic block is through blockade of peripherally located NMDA receptors that are the target in the management of neuropathic pain, with the added benefit of counteracting the “wind-up” phenomena of chronic pain. We studied ketamine as an adjuvant to the local anaesthetic for STGB in 20 cases of peripheral vascular disease of upper limbs during the last 5 years at our institution. STGB was given for 2 days with 2 ml of 2% lignocaine + 8 ml of 0.25% bupivacaine, followed by block with the addition of 0.5 mg/kg of ketamine for three consecutive days. There was significant pain relief of longer duration with significant rise in hand temperature. We also observed complete healing of the gangrenous fingers in 17/19 patients.

Hybrid Percutaneous Coronary Intervention and Minimally Invasive Reoperative Mitral Valve Surgery

We report a complex case of peripheral vascular disease (PVD), coronary artery disease (CAD), and three prosthetic heart valves, who developed severe mitral regurgitation (MR) due to healed endocarditis. She was successfully managed with a hybrid approach utilizing percutaneous coronary intervention (PCI) followed by minimally invasive mitral valve surgery (MIMVS) through right minithoracotomy. This was the patient's fifth cardiac surgery and she was discharged home on the fourth postoperative day (POD).

Relationship of periodontal attachment loss to peripheral vascular disease: An analysis of NHANES 1999–2002 data

Introduction Peripheral vascular disease (PVD) is a common disabling condition associated with many of the same risk factors as coronary heart disease. It has been suggested that periodontal disease is a risk factor for coronary heart disease but its relationship to peripheral vascular disease is under-researched. We therefore sought to evaluate the relationship of periodontal disease to PVD. Methods The study population consisted of 3585 participants who were 40 years or older when examined in National Health and Nutrition Examination Survey (NHANES) during 1999–2002. PVD was defined as an ankle-brachial index (ABI) <0.9. The presence of periodontal disease was grouped into four categories: 0%, 1–15%, 16–33% and more than 33% of sites with periodontal attachment loss (PAL) of 3 mm or more. Results Of 3585 participants, 172 (4.8%) were recognized as PVD cases. The cross-sectional associations were evaluated using multiple logistic regression considering the sampling design. After adjusting for age, gender, race, poverty, traditional risk factors of PVD and other potential confounding factors, PAL was significantly associated with PVD (odds ratio = 2.25, 95% confidence interval 1.20–4.22, p < 0.05). Systemic markers of inflammation (C-reactive protein, white blood cell count, fibrinogen) were also associated with PVD, and were also significantly associated with PAL. We therefore adjusted models including either C-reactive protein, white blood cell count or fibrinogen, the association of periodontal disease with PVD remained statistically significant but was slightly attenuated. Conclusions There appears to be a cross-sectional relationship between PAL and PVD. Inflammation may be one possible pathway to link PVD with periodontal disease.

Estimación del riesgo cardiovascular global a partir del riesgo coronario. Estudio de cohortes

The coronary risk (CR) is a good approximation of the global cardiovascular risk (GCR). Multiplying the CR per 1.3 we obtain the GCR, but we don't know if it is certain in our country.Prospective cohort study with 851 patients of ages between 35-74 years old, without cardiovascular disease and followed during 5 years. CR include myocardial ischemia (angor pectoris or myocardial infarction). GCR include CR, cerebrovascular disease, and peripheral vascular disease.We registered 21 myocardial ischemia cases, 15 cerebrovascular disease cases and 8 peripheral vascular disease cases. The accumulated incidence was: 2.5% for CR and 5.2% for GCR (difference 2.7%; 95% confidence interval for the difference 0.9-4.6%; p < 0.05). To estimated GCR we should multiple CR per 2.1.CR is not a good approximation of GCR. We need to developed equation that include not only CR but also GCR.

Maladie de Horton démasquée par une artériopathie inflammatoire spécifique des membres inférieurs

The authors report the case of a woman aged 67 years who presented an acute ischemia of the lower limbs. A surgical exploration showed no atherosclerosis or thrombus. A biopsy of the femoral artery found an extensive mononuclear cell infiltration of the media and a fragmentation of internal elastic lamina. The diagnosis of Horton disease was considered and confirmed by the presence of clinical signs of polymyalgia rheumatica and inflammatory syndrome (erythrocyte sedimentation rate: 75 mm). Corticosteroid therapy was started with success. A year after discharge there was no recurrence of ischemic manifestations and the erythrocyte sedimentation rate was normal. Involvement of lower limbs in Horton disease is rare and exceptionally proven. But postmortem studies indicate that it is more frequent than previously reported. The diagnosis should be considered in the differential diagnosis of any unexplained case of peripheral vascular disease occurring in the middle-aged or elderly.

THE ROLE OF OMENTAL TRANSFER IN BUERGER'S DISEASE: NEW DELHI'S EXPERIENCE

Buerger's disease is a specific, idiopathic, recurrent, segmental, inflammatory, obliterative vascular disease involving medium-sized arteries and veins of the limbs. We performed omental transfer on a group of patients with Buerger's disease that had previously undergone lumbar sympathectomy and the results are described. Between January 1988 and December 1993, 100 cases of peripheral vascular disease (PVD) diagnosed as Buerger's Disease were subjected to femoral angiography. Fifty cases of angiographic intermediate/distal type blocks underwent omental transposition. Of 50 patients subjected to omental transfer all had intermittent claudication, 40 had rest pain of whom 36 had non-healing ulcers, 8 had gangrene and 32 had bilateral lower limb involvement. Fifteen patients underwent bilateral omental transfer and posterior tibial artery biopsy was performed in 40. All patients showed improved skin temperature, rest pain decreased in 36 and claudication distance increased in 48. Ulcers healed in 32 of 36 patients and the line of demarcation receded in six of eight patients with gangrene. Omental transfer improved skin and muscle microcirculation and forestalled the need for amputation by providing symptomatic relief and clinically arresting the progress of Buerger's disease. Omental transfer should be considered seriously as an alternative to other modalities of therapy to delay the ischaemic complications of Buerger's disease.

Limb amputation in children in Zaria, Nigeria.

Over a period of 10 years, a total of 118 limb amputations were performed in children at the Ahmadu Bello University Hospital, Zaria, Nigeria. The major indication for limb amputation was trauma and gangrene following post-fracture splintage by traditional healers. There was no case of peripheral vascular disease in these patients. None of the patients had a prosthesis applied. The very high number of limb amputations is certainly preventable by early and effective management of fractures.

Angioscopy-Assisted Intraoperative Transluminal Angioplasty: Preliminary Report

Angioscopy as a guide for intraoperative transluminal angioplasty (ITA) was used in the treatment of 13 segmental arterial stenoses in 12 patients (10 men, 2 women). Ages ranged from fifty-eight to seventy-five years (mean: 68.33 ± 4.85). The authors successfully visualized vessels in 100% of the 12 patients, and 11 (92%) of the 12 arterial occlusive lesions were successfully dilated. Intraluminal anatomic and functional hemodynamic improvement was doc umented in all successful cases. The authors recommend angioscopy as a spe cific ancillary technique in certain cases of peripheral vascular disease during concomitant vascular surgery.

The use of sulodexide in the treatment of peripheral vasculopathy accompanying metabolic diseases. Controlled study in hyperlipidemic and diabetic subjects

Thirty vasculopathic subjects with hyperlipoproteinemia (18) and/or diabetes (22) underwent a clinical double-blind study in order to evaluate the effect of sulodexide on lipid and hemorheologic parameters. The experimental design consisted of a first 20-day i.m. therapeutic period with either sulodexide (300 Lipasemic Units twice daily via intramuscular route)or placebo and the following 70 days with the active compound for both groups at the same posology. Results obtained demostrated that sulodexide yields a hypotriglyceridemic effect on type IV hyperlipoproteinemia and hypofibrinogenic effect, as well. Moreover, this compound exerted a beneficial effect on HDL Cholesterol levels and on the antithrombin III activity by increasing both parameters significantly. Signs and symptoms were alleviated, particularly in the most severe cases of peripheral vascular disease. Insignificant and slight changes were observed at the end of treatments as regards the efficacy of the two administration routes, the i.m. one being more efficacious on lipid parameters and faster acting. No side effects or intolerance were observed during the different periods of the trial.

Validity of out-patient screening in arteriosclerosis to identify multiple lesions.

A total of 594 patients admitted for cerebrovascular disease (CVD) and for peripheral vascular disease (PVD), were examined in a study aimed at clarifying by a simple, inexpensive out-patient method, a) the relationship existing between the different locations of the vascular disease: brain, lower limbs, coronaries; b) the prevalence in the patients studied of risk factors such as hypertension, hyperlipidaemia and diabetes, and of migraine. The results were as follows: a) of the patients admitted for CVD, 44% also presented arteriosclerosis in other locations; this figure was 32% for PVD cases; b) hypertension was found in 38.5% of CVD and 27% of PVD cases; diabetes in 11.5% of CVD and in 18% of PVD cases; hyperlipidaemia in 31% of CVD and 24% of PVD cases; migraine in 11% of CVD and 1% of PVD cases.

Peripheral gangrene in polycythaemia vera

Summary A case of peripheral vascular disease which became gangrenous and led to a diagnosis of polycythaemia vera is described. Chemotherapy has been successful and surgical intervention avoided. The authors stress the importance of full haematological examination of any patient presenting with peripheral digital gangrene.