Masson Tumor of the Heel Fat Pad.

ABSTRACT: Intravascular papillary endothelial hyperplasia (Masson tumor) is an uncommon benign vascular lesion characterized by a reactive proliferation of endothelial cells. This lesion commonly occurs in the head, neck, and upper extremities. Although it can be found anywhere in the body, the lesion has never affected the heel fat pad. This report presents a rare case of Masson tumor of the heel fat pad to facilitate the recognition of this uncommon lesion and also suggests other conditions to be considered when diagnosing heel lesions.

Double Primary Malignancies Involving Cutaneous Carcinoma.

ABSTRACT: Multiple primary malignancies (MPMs) refer to the presence of 2 or more histologically distinct malignant tumors in the same individual. The prevalence of MPMs has increased owing to earlier detection of tumors by screening tests and improved treatment modalities for primary tumors. Although any combination of malignant tumors is possible, reports of MPMs involving cutaneous carcinoma are uncommon in the literature. Herein, we present 2 uncommon cases of synchronous double primary malignancies involving basal cell carcinoma and primary cutaneous mucinous carcinoma as the index tumors, accompanied by a thyroid carcinoma and a thymoma as the second malignancy, respectively. The authors also describe the usefulness of positron emission tomography/computed tomography for detecting occult primary tumors in patients with cutaneous malignancies.

Pseudocystic pilomatricoma: A new variant and review of the literature.

A classic pilomatricoma, which usually presents with an asymptomatic, solitary, firm, subcutaneous nodule in the head, neck, or extremities of the paediatric population, is easily diagnosed based on its characteristic clinical and histopathological features. However, its variants often pose particular diagnostic challenges to clinicians due to their rarity and diverse clinicopathological features. We present a new pseudocystic variant, manifesting as solid lesions floating in a fluid-filled sac.

ZW800-PEG: A Renal Clearable Zwitterionic Near-Infrared Fluorophore for Potential Clinical Translation.

Near-infrared (NIR) fluorescence imaging has advanced medical imaging and image-guided interventions during the past three decades. Despite tremendous advances in imaging devices, surprisingly only a few dyes are currently available in the clinic. Previous fluorophores, ZW800-1A and ZW800-1C, significantly improved the poor performance of the FDA-approved indocyanine green. However, ZW800-1A is not stable in serum and ZW800-1C induces severe stacking in aqueous media. To solve such dilemmas, ZW800-PEG was designed by introducing a flexible yet stable thiol PEG linker. ZW800-PEG shows high solubility in both aqueous and organic solvents, thus improving renal clearance with minimal binding to serum proteins during systemic circulation. The sulfide group on the meso position of the heptamethine core improves serum stability and physicochemical properties including the maximum emission wavelength shift to 800 nm, enabling the use of ZW800-PEG for image-guided interventions and augmenting photothermal therapy.

Giant Mixed Tumor of the Skin Affecting the Hemiface.

Mixed tumor of the skin (MTS) is a rare skin adnexal neoplasm occurring in sweat glands. It is usually benign, measures 0.5 to 3 cm, and presents as a slowly growing, painless, firm nodule commonly in the head and neck regions. Owing to its rarity and lack of distinctive clinical manifestations, confirmative diagnosis is made on the basis of its pathologic features. Malignant MTS also develops de novo or from preexisting benign MTS even though they occur rarely. It should be excised completely to exclude malignant potentials. Herein, we report a 35-year history of a giant MTS of eccrine type measuring approximately 10.5 × 6.5 cm on the right hemiface of a 91-year-old woman, which is the largest facial MTS reported in the literature so far, to the best of our knowledge.

Protective effects of 6-ureido/thioureido-2,4,5-trimethylpyridin-3-ols against 4-hydroxynonenal-induced cell death in adult retinal pigment epithelial-19 cells.

Dysfunction or progressive degeneration of retinal pigment epithelium (RPE) contributes in the initial pathogenesis of age-related macular degeneration (AMD) causing irreversible vision loss, which makes RPE the prime target of the disease. The present study aimed to identify compounds to protect 4-hydroxynonenal (4-HNE)-induced RPE cell death by inhibiting NADPH oxidase 4 (NOX4) activity, not just as free radical scavengers, using ARPE-19, a human adult retinal pigment epithelial cell line, as a RPE representative. Novel thirty-two 6-ureido/thioureido-2,4,5-trimethylpyridin-3-ol derivatives 17 were synthesized and tested. We found that there was a strong correlation between level of protective effect of compounds 17 against 4-HNE-induced APRE-19 cell death and that of inhibitory activity against 4-HNE-induced superoxide production, and that most of the compounds 17 showed minimal DPPH radical scavenging activity. Compound 17-28 showed the best protective activity against 4-HNE-induced superoxide production (79.5% inhibition) and cell death (85.1% recovery) at 10 µM concentration, which was better than that of VAS2870, a NOX2/4 inhibitor. In addition, compound 17-28 blocked 4-HNE-induced apoptosis of ARPE-19 cells in a concentration-dependent manner. The results indicate that compound 17-28 may be a lead compound to develop AMD therapeutics.

Determination of the Amount of Ptosis Correction in Levator Resection Surgery for Pediatric Congenital Ptosis.

BACKGROUND: It is difficult to determine the amount of eyelid lift in levator resection surgery for congenital ptosis, especially when the surgery is performed under general anesthesia. We aim to introduce an objective and steady method with which to adjust eyelid height, and to identify other factors to be considered during surgery. METHODS: This is a retrospective, observational study of 110 eyes from 78 patients who underwent levator resection surgery for congenital ptosis. Postoperative eyelid height was observed chronologically. The amount of eyelid lift during surgery was compared with the real postoperative change of palpebral fissure width (PF). The factors influencing the postoperative changes in eyelid height were investigated to predict outcome. RESULTS: Postoperative eyelid height stabilized 1 month after surgery. The real postoperative change in PF was slightly larger than the amount of intraoperative eyelid lift in cases with levator muscle function (LF) ≥ 7 mm, whereas it tended to be smaller in cases with LF < 5 mm. Statistically significant factors influencing the difference between the amount of intraoperative eyelid lift and the real postoperative change of eyelid height included preoperative PF, preoperative LF, and anesthesia-induced lagophthalmos. CONCLUSION: The preoperative PF, preoperative LF, and anesthesia-induced lagophthalmos should be considered when determining the amount of ptosis correction to perform in levator resection surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Prospective, Comparative Study of the Pain of Local Anesthesia Using 2% Lidocaine, 2% Lidocaine With Epinephrine, and 2% Lidocaine With Epinephrine-Bupivicaine Mixture for Eyelid Surgery.

PURPOSE: A mixture of 2% lidocaine with epinephrine and bupivacaine was developed to achieve the fast-onset anesthetic effect of lidocaine and the long-lasting effect of bupivacaine. The authors compared pain scores between 2% lidocaine, 2% lidocaine with epinephrine, and 2% lidocaine with epinephrine-bupivicaine mixture during local anesthesia for eyelid surgeries. METHODS: This was a double-blind, randomized, prospective, comparative study. In total, 120 consecutive patients (43 males, 77 females, mean age = 47.2 ± 21.2) who underwent bilateral eyelid surgery under subcutaneous anesthesia were asked to report pain scores for each eye during the first injection of anesthesia. Each patient was randomly assigned to receive 1 of the 3 anesthetic agents in 1 eyelid, and 1 of the remaining 2 agents in the other. RESULTS: The pH values of the 2% lidocaine, 2% lidocaine with epinephrine, and 2% lidocaine with epinephrine-bupivicaine mixture were 6.23 ± 0.21, 4.21 ± 0.37, and 3.87 ± 0.19, respectively. The pain scores of each were 4.3 ± 1.8, 5.1 ± 1.8, and 5.7 ± 1.9, respectively. The 2% lidocaine with epinephrine produced a statistically significantly higher pain score than 2% lidocaine (p = 0.044, generalized estimating equation method). The mixture also showed a significantly higher pain score than 2% lidocaine (p = 0.003, generalized estimating equation method). CONCLUSIONS: Epinephrine seemed to increase subjective pain scores. Compared with 2% lidocaine with epinephrine, 2% lidocaine with epinephrine-bupivicaine mixture was not significantly different in terms of subjective symptoms or pH.

Natural, semisynthetic and synthetic tyrosinase inhibitors.

Tyrosinase plays a pivotal role in the synthesis of melanin pigment synthesis on skin utilizing tyrosine as a substrate. Melanin is responsible for the protection against harmful ultraviolet irradiation, which can cause significant pathological conditions, such as skin cancers. However, it can also create esthetic problems when accumulated as hyperpigmented spots. Various skin-whitening ingredients which inhibit tyrosinase activity have been identified. Some of them, especially ones with natural product origins, possess phenolic moiety and have been employed in cosmetic products. Semi-synthetic and synthetic inhibitors have also been developed under inspiration of the natural inhibitors yet some of which have no phenolic groups. In this review, tyrosinase inhibitors with natural, semi-synthetic and synthetic origins are listed up with their structures, activities and characteristics. Further, a recent report on the adverse effect of a natural melanin synthesis inhibitor which was included in skin-whitening cosmetics is also briefly discussed.

An Alternative to the Wire Scalpel for Nasolabial Fold Subcision: A Preliminary Study Using a Tuohy Epidural Needle and Vicryl Sutures.

BACKGROUND: Subcision techniques involving wire scalpels are used to correct prominent nasolabial folds, depressed scars, and wrinkles. However, these instruments are not universally available. METHODS: We devised a substitute device, consisting of a Tuohy epidural needle and Vicryl sutures, which are easily accessible and inexpensive. We used these novel devices to perform nasolabial fold subcisions in six female patients (mean age 43 years, range 28-65 years) The follow-up period ranged from 4 to 11 months (mean 7 months). RESULTS: Favorable results were obtained for five of six patients, with minimal complications. CONCLUSION: Our subcision technique, employing Tuohy epidural needles and vicryl sutures, was an easy and useful substitute for the use of wire scalpels for improving prominent nasolabial folds. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postoperative outcomes of anophthalmic socket reconstruction using an autologous buccal mucosa graft.

Socket contracture is one of the most common and difficult problems in anophthalmic patients. This study intended to evaluate postoperative outcomes of anophthalmic socket reconstruction using an autologous buccal mucosa graft in patients with socket contracture. Medical records and photographs of 44 anophthalmic patients who underwent socket reconstruction surgery using an autologous buccal mucosa graft were reviewed retrospectively. The time necessary for the graft surface to be completely vascularized was assessed, and fornix depth was measured before and 6 months after surgery. Postoperative cosmetic and functional outcomes were evaluated, and the factors that influence postoperative outcomes were investigated. The surgery was performed without any significant complications, and the patients only complained of oral discomfort within 1 week. The graft surface was fully vascularized about 1.1 months after surgery. Mean fornix depth after surgery was significantly deeper than that before surgery (9.1 mm, about 68.2% of the vertical size of the implanted graft). Preoperatively, 50.0% of the patient had cosmetic grades 1 and 2; however, 63.6% of the patients achieved grade 4, and 93.2% had higher than grade 3 after surgery. In functional outcomes, 86.4% of the patients presented functional success. Graft recontracture occurred in only 2 patients. Preoperative severe socket contracture was a factor associated with worse cosmetic outcome (P = 0.001). An autologous buccal mucosa can be a safe and effective graft material for the reconstruction of a contracted socket.

Marginal ectropion induced by conjunctival ingrowth after levator resection surgery.

BACKGROUND: Levator resection surgery is commonly performed to correct ptosis, and a large number of postoperative complications are well known. This report presents a previously unreported complication of marginal ectropion after levator resection surgery for congenital ptosis. METHODS: The three patients with upper eyelid marginal ectropion in this observational case series previously had undergone levator resection surgery for congenital ptosis. The patients' medical records and clinical photographs were reviewed retrospectively. The patients underwent reoperations for ectropion correction. Unusual tissues identified during the surgery were excised and processed for histopathologic analysis. RESULTS: The patients presented with upper eyelid marginal ectropion and had a history of levator resection surgery for congenital ptosis on the same eye. Ingrown tissues were observed during the second operations for ectropion correction in all three patients. Histopathologic analysis was performed for two of the patients, confirming that the tissue consisted of mucosa. The ectropions were corrected after surgical removal of the ingrown tissues. CONCLUSIONS: Marginal ectropion can occur after levator resection surgery. In this study, the ectropion was attributed to mucosal ingrowth, a complication not previously reported. To improve the surgical outcomes, surgeons should be aware of this complication. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Proteomic analysis of novel targets associated with TrkA-mediated tyrosine phosphorylation signaling pathways in SK-N-MC neuroblastoma cells.

Tropomyosin-related kinase A (TrkA) is a receptor-type protein tyrosine kinase and exploits pleiotypic roles via nerve growth factor (NGF)-dependent or NGF-independent mechanisms in various cell types. Here, we showed that the inhibition of TrkA activity by GW441756 resulted in the suppression of tyrosine phosphorylation of cellular proteins including extracellular signal-regulated protein kinase (ERK) and c-Jun N-terminal kinase (JNK). To find novel targets associated with TrkA-mediated tyrosine phosphorylation signaling pathways, we investigated GW441756 effects on TrkA-dependent targets in SK-N-MC neuroblastoma cells by proteomic analysis. The major TrkA-dependent protein spots controlled by GW441756 were determined by PDQuest image analysis, identified by MALDI-TOF MS and MALDI-TOF/TOF MS/MS, and verified by 2DE/Western blot analysis. Thus, we found that most of the identified protein spots were modified forms in a normal condition, and their modifications were regulated by TrkA activity. Especially, our results demonstrated that the modifications of α-tubulin and heterogeneous nuclear ribonucleoproteins C1/C2 (hnRNP C1/C2) were significantly upregulated by TrkA, whereas α-enolase modification was downregulated by TrkA, and it was suppressed by GW441756, indicating that TrkA activity is required for their modifications. Taken together, we suggest here that the major novel TrkA-dependent targets such as α-tubulin, hnRNP C1/C2, and α-enolase could play an essential role in TrkA-mediated tyrosine phosphorylation signaling pathways via regulation of their posttranslational modifications.

Pirfenidone attenuates IL-1ß-induced COX-2 and PGE2 production in orbital fibroblasts through suppression of NF-κB activity.

The aim of this study was to determine the effect of pirfenidone on interleukin (IL)-1ß-induced cyclooxygenase (COX)-2 and prostaglandin (PG)E2 expression in orbital fibroblasts from patients with thyroid-associated ophthalmopathy (TAO). Primary cultures of orbital fibroblasts from patients with TAO (n = 4) and non-TAO subjects (n = 4) were prepared. The level of PGE2 in orbital fibroblasts treated with IL-1ß in the presence or absence of pirfenidone was measured using an enzyme-linked immunosorbent assay. The effect of pirfenidone on IL-1ß-induced COX-2 expression in orbital fibroblasts from patients with TAO was evaluated by reverse transcription-polymerase chain reaction (PCR) and quantitative real-time PCR analyses, and verified by Western blot. Activation of nuclear factor-κB (NF-κB) was evaluated by immunoblotting for inhibitor of κB (IκB)α and phosphorylated IκBα, and DNA-binding activity of p50/p65 NF-κB was analyzed by electrophoretic mobility shift assay. In addition, IL-1 receptor type 1 (IL-1R1) expression was assessed by RT-PCR in IL-1ß-treated cells with or without pirfenidone. Pirfenidone significantly attenuated IL-1ß-induced PGE2 release in both TAO and non-TAO cells. IL-1ß-induced COX-2 mRNA and protein expression decreased significantly following co-treatment with pirfenidone. IL-1ß-induced IκBα phosphorylation and degradation decreased in the presence of pirfenidone and led to decreased nuclear translocation and DNA binding of the active NF-κB complex. In our system, neither IL-1ß nor pirfenidone co-treatment influenced IL-1R1 expression. Our results suggest that pirfenidone attenuates the IL-1ß-induced PGE2/COX-2 production in TAO orbital fibroblasts, which is related with suppression of the NF-κB activation.

Variations in the degree of epiblepharon with changes in position and induction of general anesthesia.

BACKGROUND: To investigate the changes of epiblepharon by evaluating the severity of epiblepharon before and after induction of general anesthesia. METHODS: Sixty-three pediatric patients (126 eyes) underwent surgery for epiblepharon between April 2008 and September 2008 (35 females, 28 males; average age: 4.74 years). The severity of epiblepharon in each eye was scored according to skin-fold height (scored 1-4) and area of ciliocorneal touch (scored 1-3) while the patient was in upright and supine positions before induction of general anesthesia and in supine position after induction of anesthesia. RESULTS: The severity of epiblepharon was significantly reduced by a positional change to supine position and induction of general anesthesia. Skin-fold height scores decreased when patients were moved from upright (estimated mean ± standard error [SE]; 2.98 ± 0.08) to supine position (2.63 ± 0.09) (P < 0.001) prior to induction of anesthesia, and decreased further after induction of general anesthesia (2.12 ± 0.08) (P < 0.001). Ciliocorneal touch scores also decreased after patients were moved to supine position and after induction of general anesthesia (upright: 2.17 ± 0.05; supine: 1.95 ± 0.06; general anesthesia: 1.64 ± 0.07, P < 0.001). CONCLUSIONS: Our study demonstrates that positional changes and general anesthesia using muscle relaxants affect the degree of epiblepharon. Surgeons should be aware of these variations for operative planning of epiblepharon.

Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections.

BACKGROUND: To evaluate the efficacy of subconjunctival triamcinolone injection for treating upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO). METHODS: Prospective single blind randomized clinical trial. Patients diagnosed with TAO-associated eyelid retraction and/or swelling <6 months before study onset were randomly assigned to triamcinolone-injected (group I; 55 patients, 75 eyes) or observation-only (group II; 40 patients, 59 eyes) populations. Group I received 1-3 injections of 20 mg triamcinolone acetate into the subconjunctival eyelid, between the conjunctiva and Muller's muscle, at 3-week intervals. Group I was followed up at 3, 6, 9, and 24 weeks post-injection, and group II was evaluated at 9 and 24 weeks after initial visit. Eyelid swelling and retraction were each graded on a 0-3 scale. Treatment was stopped after 1-2 injections if both swelling and retraction resolved completely or if retraction and swelling scored 0/1 or 1/0 without functional or cosmetic patient concerns. Treatment success was defined at 9 and 24 weeks post-injection if eyelids were normal or when treatment was terminated because of early clinical resolution. We compared baseline clinical data between success and failure group evaluated at 9 and 24 weeks in group I, and investigated short-term and long-term success prognostic factor using multiple logistic regression analysis in each group I and II. RESULTS: Swelling and retraction decreased significantly more in group I than in group II. Significantly more eyes had severe swelling (≥ grade 2) in group I (67 %) than in group II (34 %) upon initial evaluation (p < 0.01); this difference disappeared at 9 and 24 weeks. Fewer severely retracted eyes were observed in group I than in group II at 9 and 24 weeks (p < 0.01). Significantly more eyes in group I achieved success at both 9 and 24 weeks (59 %, 75 %) than in group II (39 %, 57 %) (p = 0.03, p = 0.04 respectively). Higher initial retraction grades (2-3) predicted a higher chance of post-injection failure versus the reference group (grade 0-1) at 9 and 24 weeks in group I, with adjusted odds ratios (aOR) 45.4 (95 % CI = 5.9-351.1, p < 0.01) and aOR 11.6 (95 % CI = 2.3-58.5, p < 0.01) respectively. Similarly in group II, initial retraction grade was associated with the failure at 9 and 24 weeks, with aOR 10.3 (95 % CI = 1.8-59.6, p < 0.01) and aOR 5.9 (95 % CI = 1.3-25.9, p < 0.05) respectively. Transient intraocular pressure elevation was observed in three eyes of two patients, although all ocular pressures were normalized within 1 month using anti-glaucoma medication. CONCLUSIONS: Subconjunctival triamcinolone injections were very effective in resolving eyelid swelling and retraction in recent-onset TAO. However, the symptom-reducing effect of triamcinolone was modest and less effective in patients initially presenting with severe retraction grades. As intraocular pressure may rise after steroid injection at upper eyelid, the treatment should be avoided in patients suspected to have glaucoma.

Factors associated with diabetic retinopathy and nephropathy screening in Korea: the Third and Fourth Korea National Health and Nutrition Examination Survey (KNHANES III and IV).

This cross-sectional study was done to identify and determine the socio-demographic and health-related factors associated with diabetic retinopathy and nephropathy screening in Korea. Participants included 2,660 adults, aged 40 or older, with diabetes. Of the 2,660 adults, 998 (37%) and 1,226 (46.1%) had received a diabetic retinopathy and a nephropathy screening within one year, respectively. Regarding retinopathy, subjects older than 65, living in urban areas, with high educational levels, and with self-reported "unhealthy" status were likely to receive annual screening. Subjects living in urban areas, with higher educational levels, with self-reported "fair" or "unhealthy" status, and with 1 to 2 co-morbidities were likely to receive annual nephropathy screening. The Korea Composite Stock Price Index (KOSPI) continued to rise until 2007 when it started to decline over the subsequent years, following the same curve as the diabetic retinopathy and nephropathy screening rates during that time. Together with the financial matter, lack of patient education proved to be a hindrance to diabetes-related screening. The relatively low screening rates in Korea compared to the Western countries are likely to be due to the difference in the health system, economic situations and national demographics.

Supporting implant technique for repairing large medial orbital wall fractures.

PURPOSE: To introduce a new surgical technique for repairing large medial wall fractures stably with insufficient bony structures. METHODS: This is a case series of 29 patients who underwent surgery for repairing large medial wall fractures using the new supporting implant technique in Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. Medical records and radiologic images of the patients were reviewed retrospectively. The outcomes evaluated were the incidence and the degree of diplopia and enophthalmos, and orbital volume restoration after surgery. The institutional review board approved this study, and the study adhered to the tenets of the Declaration of Helsinki. RESULTS: Orbital reconstruction using the supporting implant technique was performed without any complications. The incidence of diplopia was 51.7% including 6.9% of significant diplopia before and 27.6% with no significant diplopia 3 months after surgery (p = 0.022). The average enophthalmos was successfully corrected from 0.93 mm preoperatively to 0.36 mm at 3 months postoperatively (p = 0.001). Orbital volume was corrected from 25.71 to 23.59 cm2 after surgery, which was not significantly different from the contralateral unaffected orbit (p = 0.157). CONCLUSIONS: The supporting implant technique is a simple and effective surgical method that provides sufficient support and prevents implant migration in large medial orbital wall fractures.

Early-Stage Pilomatricoma with Cystic Features: A Case Report and Literature Review.

A conventional pilomatricoma presents as an asymptomatic, firm, subcutaneous nodule, commonly in the head, neck, and extremities of the paediatric population. However, its variants show diverse clinical features, which often pose a diagnostic challenge to clinicians. We recently treated an unusual case of pilomatricoma with cystic features in the upper chest of a 9-year-old girl, which manifested as a single solid tumour floating in a serous-filled sac formed by thick fibrous tissue. Herein, we present novel clinicopathological features of an early-stage pilomatricoma that should be clinically differentiated from a cutaneous abscess.

Salvage percutaneous transluminal angioplasty of the superficial femoral artery in the diabetic foot with deteriorating limb ischemia.

INTRODUCTION: PAD frequently co-occurs with diabetes, often leading to chronic nonhealing wounds. Foot gangrene and amputation are common outcomes of untreated CLI. CASE REPORT: A 67-year-old male with diabetes and deteriorating limb ischemia following surgical stress underwent successful surgical repair after emergency PTA of the SFA for extensive heel necrosis. After surgical debridement of necrotic heel tissue, the ABI on the affected side suddenly reduced to 0.36, but it improved to 1.06 at 4 weeks following stenting angioplasty, allowing the subsequent flap surgery to repair the heel defect. At the 1-year follow-up visit, the patient exhibited durable heel coverage and the restoration of weightbearing function. No signs or symptoms indicative of restenosis were evident in the blood vessel treated with stent angioplasty. CONCLUSION: This case highlights the importance of proper evaluation of critical ischemic conditions and the need for prompt endovascular interventions in preserving the at-risk diabetic foot.