Case 111: Natural Course of Ischemic Necrosis in Diabetic Depressed Woman with Severe Arteriosclerotic Cardiomyopathy Who Refused Local Care and Boot Therapy

This elderly lady was referred from another hospital for boot therapy. She arrived, however, with a signed document expressing her desire not to undergo any unusual therapies. She did try the Mini-Boot and found it tolerable. She found therapy with the Long-Boot painful and declined all further therapy. Her records showed that she had a stenotic right deep femoral, multiple stenoses in her superficial femoral with a complete occlusion at the adductor canal, a calcified and stenotic popliteal, occlusions of her peroneal and posterior tibial arteries and proximal stenoses in her posterior tibial artery. Faint Doppler sounds were present in the posterior tibial at the ankle while the distal foot was quiet. She was provided parenteral antibiotics and pain medications in the nursing home.

She presented with gangrene of the distal half of her second toe.

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Subsequently, the 2nd and 3rd toes mummified as did the tissue above and below their metatarsal heads. Foci of necrosis developed in her arch.

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The 1st and 4th toes likewise began to necrose.

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Comments: Chronic pain and disability sap the will of many patients. This lady had deteriorated over weeks prior to her referral. She continued the process in the nursing home. The Long-Boot is a life support device. Many debilitated patients perk up during their treatment programs. Earlier referral might have helped. Again, since her heart disease was thought to negate the possibility of surgery by her physicians, one might question the need to perform her arteriogram; her noninvasive testing pointed to diffuse disease unlikely to be benefited by angioplasty. The natural deterioration of the ischemic foot was also shown in case 103. These feet can be very painful..

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