Ischemic Limb Gangrene with Pulses

To the Editor: Warkentin (Aug. 13 issue)1 highlights the misconception that all cases of ischemic limb gangrene are associated with the loss of an arterial pulse and presents the two syndromes associated with disseminated intravascular coagulation in which ischemic limb gangrene can occur with a pulse. However, in so doing, he may have created another misconception — the idea that ischemic limb gangrene with pulses is related to syndromes associated with disseminated intravascular coagulation. It is important to recognize that ischemic limb gangrene with pulses can occur without associated disseminated intravascular coagulation, as it does in calcific uremic arteriolopathy (calciphylaxis)2 and cholesterol embolization (atheroembolism).3 Cholesterol embolization should not be confused with arterial thrombosis.4 It is important to consider these possibilities in the differential diagnosis of ischemic limb gangrene with pulses. In a simplified approach to patients with limb gangrene, the clinician should first determine whether a pulse is present; if it is, the differential diagnosis should be based on whether there is an association with disseminated intravascular coagulation (Fig. 1).