A sacral ulcer is described where ischaemia due to a vascular "steal" syndrome in the gluteal angiotome was the cause of persistent failure of flap reconstruction. Thrombotic obliteration of the abdominal aorta had resulted in the development of collaterals which, paradoxically, deprived the flaps based on standard angiotomes of their major source of blood supply, as they became the major source of perfusion for the legs. Healing of the ulcer was successfully achieved only after aorto-iliac reconstruction. Two other cases of ischaemic sacral ulceration, associated with aortic occlusion, are described.
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