 
|
Perspectives in Circulation Today
The Gangrenous Foot. A simple classification and its Treatment with the End-diastolic pneumatic boot
Dry Gangrene:
The above is "Case 3" taken from the Case History section of the Circulator Boot web site. It illustrates the features found in advanced cases of dry gangrene associated with arteriosclerosis obliterans:
Characteristics of gangrene associated with ischemia:
Devitalization process worsens proximally to distally. Mummification of the distal tissues may occur distal to the level where detectable blood flow ends. Black eschar may also form at pressure points.
The temperature of the foot, when measured with thermocouples in a room held constant at 20 degrees C, is close to room temperature and occasionally below it. (Horwitz O and Abramson DG: A modification of the vasodilatation test. Am J Cardiology 6:663, 1960. Patients warmed under blankets with toes bare in a 20 degree Centigrade constant temperature room. Toe temperatures: degree of impairment: none >30, slight 28-30, moderate 25-28 and severe 21-25 degrees centigrade. Amputation seldom necessary with results over 26 degrees centigrade.). Estimates of temperature by palpation are not reliable.
Pregangrenous changes may have been appreciated:
Acute ischemia may have been documented:
Pain may be proportional to the acuteness of the ischemia..
Pallor of the foot may be elicited by raising the foot to some level. Rubor returns on dependency , more slowly and with deeper color in the more ischemic feet. Failure of the color to blanch on elevation or local pressure may signify extravasation of blood and impending tissue breakdown.
The vascular laboratory expected to find values at or below those associated with nonhealing ulcers and amputation failures: toe blood pressure < 15 mm Hg, ankle BP <40 mm Hg, transcutaneous PO2 <20 mm Hg, transcutaneous PCO2 42.3±6.4 mm Hg. (see Circulatorboot.com/literature/vasctest.html).
Treatment of the gangrenous foot: Distal bypasses had been attempted and failed in the above patient. In general, the more advanced the ischemia and necrosis, the harder revascularization procedures are to perform. Still the possibility of surgical revascularization should be considered in all such patients. They should not be attempted if the outlook for success is poor. The patient has to recover from both his disease and the surgery if the procedure does not measurably improve the circulation. Patients with heart disease, of course, have increased risk with any operative procedure with bypass having less risk than a major leg amputation. Long Circulator Boot therapy, in contrast, supports both the peripheral circulation and heart function. Abstracts of studies providing the statistics for these observations may be found on our website: www.circulatorboot.com/literature/litmenu.html. On presentation, this man was advised (1) his leg could be saved with boot therapy; (2) the advanced necrosis could autoamputate leaving a workable foot; (3) several months of therapy would be involved as it would be if autoamputation were to be attempted following a successful bypass procedure; and (4) it was likely booting would improve his heart function. As seen below all of this was accomplished. Not mentioned were the treatments of his other leg which was healed also with boot treatments. His leg is seen at follow-up five years later.
In future Newsletters we shall look at gangrene due to necrosing cellulitis (wet gangrene) and arteritis. Their clinical features differ significantly as does the booting techniques employed in their treatment. For our method of treatment see www.circulatorboot.com/literature/angiology2.html.