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Figure 1. A 39-year-old man with a 22-year history of smoking one to two packs of cigarettes per day was referred to our hyperbaric facility because of an ulcer on the tip of the third finger of his right hand that had been present for six months (Panel A). He had a four-year history of blanching and coldness of the fingers on exposure to cold, and a previous ulcer of the tip of the left index finger had healed when he stopped smoking. The second ulcer appeared when he resumed smoking, but it did not heal when he again stopped smoking. The ulcer had not responded to treatment with prazosin, nifedipine, or topical nitroglycerin. Examination disclosed diminished pedal pulses and poor vascular collateralization of the right hand on Allen's test. An angiogram of the right hand (Panel B) demonstrated multiple chronic occlusions of the digital branches that were unresponsive to intraarterial vasodilators, supporting the diagnosis of thromboangiitis obliterans. After 51 hyperbaric treatments, with concurrent blockade of the right stellate ganglion twice weekly, the size of the ulcer was reduced by approximately 50 percent (Panel C). Because healing by second intention could not be achieved over the exposed necrotic bone, primary closure by skin flap was performed in conjunction with postoperative hyperbaric treatments to ensure healing (Panel D). The patient has not resumed smoking.
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