A 58-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, and heavy tobacco use presented with a 3-month history of an ulcer on her left thigh. On review of her systems, an intermittent claudication in both legs was noted. Physical examination revealed a 3 × 5-cm ulcer within a 10 × 15-cm firm, red-violaceous plaque on the left medial-posterior thigh (Figure 1). Peripheral pulses in the bilateral lower extremities were not palpable. A biopsy specimen of the left thigh plaque revealed a dense proliferation of uniform spindle cells in the papillary and upper reticular dermis forming small vascular spaces (Figure 2, A and B). When examined with immunoperoxidase staining, the spindle cells stained positively with vascular markers CD31 and CD34 (Figure 2C). These cells were closely associated with cells staining positively with smooth muscle actin. A noninvasive peripheral vascular study revealed significant bilateral ischemic disease in the legs; the disease was greater on the left side (Figure 3).