A 64-year-old man with a history of arterial hypertension; diabetes mellitus; chronic kidney disease stage V; dilated, non-ischemic cardiomyopathy; status post-aortic valve replacement, was treated in our outpatient pre-dialysis clinic. He presented with volume overload and a necrotizing, non-healing skin ulcer. He had been treated with warfarin for several years due to the mechanical valve. The patient complained of severe leg pain and denied any trauma. He reported that the skin ulcer had developed from a small, erythematous plaque to a necrotizing lesion over several days.