Arterial insufficiency ulcers (also known as ischemic ulcers, or ischemic wounds) are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD). Characteristics
The ulcer has punched-out appearance. It is intensely painful. It has gray or yellow fibrotic base and undermining skin margins. Pulses are not palpable. Associated skin changes may be observed, such as thin shiny skin and absence of hair. They are most common on distal ends of limbs. A special type of ischemic ulcer developing in duodenum after severe burns is called Curlings ulcer. Cause
The ulcers are caused by lack of blood flow to the capillary beds of the lower extremities. Most often endothelial dysfunction is causative factor in diabetic microangiopathy and macroangiopathy. In microangiopathy, neuropathy and autoregulation of capillaries leads to poor perfusion of tissues, especially wound base. When pressure is placed on the skin, the skin is damaged and is unable to be repaired due to the lack of blood perfusing the tissue. The wound has a characteristic deep, punched out look, often extending down to the tendons. The wounds are very painful. Diagnosis
The lesion can be easily identified clinically. Arterial doppler and pulse volume recordings are performed for baseline assessment of blood flow. Radiographs may be necessary to rule out osteomyelitis. Differential diagnoses
Neuropathic ulcer
Gangrene
Infected wound

Management
The prevalence of arterial insufficiency ulcers among people with Diabetes is high due to decreased blood flow caused by the thinning of arteries and the lack of sensation due to diabetic neuropathy.
A retrospective study in Turkey found that the prevalence of Sheehan’s syndrome was directly proportional to the amount of at-home deliveries each decade. This may be due to previously limited obstetric techniques present in a home environment. For example, an area of improvement in preventing the condition could be an increase in the efficacy of treatment to hypovolemic shock through blood transfusion.Pituitary necrosis may directly result from a lack of blood flow in the hypophyseal artery as a result of pituitary gland enlargement during pregnancy. One cause of pituitary growth associated with the risk of Sheehan’s syndrome is the hyperplasia of lactotrophs (responsible for prolactin production). Ischemia may occur as a result of vasospasm, thrombosis, or vascular compression sometimes as a result of an increase in the amount of lactotroph cells throughout gestation (contributing to the enlargement of the pituitary gland). Necrosis may occur as a result of severe hypotension or shock due to excessive uterine bleeding following childbirth. Sheehan’s syndrome may occur as a result of the arterial constriction and abnormal hypotension in conjunction with an insufficiency to meet the increased demand in blood supply of the pituitary gland seen during pregnancy. This increased blood-flow and metabolic demand is associated with the previously mentioned hyperplasia of lactotrophs.Some possible predisposing factors to Sheehan’s syndrome may include: inherited or acquired disseminated blood coagulation (DIC), restriction pituitary blood supply, small sella size, vasospasm, or thrombosis.