Author Affiliations: From New York Presbyterian Hospital and Columbia University Medical Center, New York, NY. Correspondence: Nicholas J. Morrissey, MD, Assistant Professor of Surgery, Columbia/Weill Cornell Division of Vascular Surgery, the New York Presbyterian Hospital, Irving Pavilion 639, 161 Fort Washington Ave, New York, NY 10032. E-mail: email@example.com. Disclosure: The author reports no financial relationships or conflicts of interest regarding the content therein. _____________________________ The report by de Donato and colleagues1 on the impact of iloprost on outcomes after the treatment of acute ischemia provides insight into the mechanism and prevention of adverse effects related to ischemia and its treatment. The authors based their current randomized, double-blind controlled study on preliminary data, which showed potential benefit from iloprost. The investigators are to be congratulated for their foresight in choosing this particular agent based on its pharmacology and use in other clinical arenas. The critically important concept that adverse cardiovascular outcomes and death can be related to the lingering effects of ischemia/reperfusion on the already compromised patient is the foundation for this study. While amputation plus death were not reduced in the iloprost group overall, death was significantly reduced, as were all cardiovascular adverse events related to reperfusion. The importance of these data are suggested by the authors when they claim that amputation itself may be more related to anatomic and surgical conditions, while overall survival and cardiovascular events may be more subject to ischemia/reperfusion phenomena. The data from this well-designed study do suggest that iloprost, well tolerated in this series, may provide an ameliorative effect on the impact of ischemia/reperfusion on mortality and adverse cardiovascular events. The results of this study remind one of the original data suggesting that beta-blockers could improve outcomes following major vascular surgery. The outcomes of both interventions are based on improving the overall condition of the patient by attenuating the physiologic insult of surgery or pathology. Based on the quality of the study and the clear results, the authors’ suggestion that iloprost may be useful to improve outcomes following treatment of acute ischemia seems valid. In addition, the suggestion that larger studies analyzing the impact of this agent should be performed is reasonable, and more data are needed before widespread use of iloprost can be advocated.