Case 136: Cold Painful Leg after Embolectomies, Heparin and Coumadin. No Benefit from 12th Hour Boot Therapy. AK-Amputation

This 68 year old man had a history of previous myocardial infarction, steroid treatment for rheumatoid arthritis, 40-pack years of cigarette smoking and a cool left leg. On this occasion, he had first been admitted to the coronary care unit with chest pain and various arrhythymias. Associated with the arrhythmia he had a subendocardial myocardial infarction on the third hospital day. On the 19th hospital day, his previous cool foot was found to be cold and numb and he had pain in his calf and thigh. An arteriogram showed that the superficial femoral was occluded in its mid portion. He had an "embolectomy" and large amounts of clot were removed from the distal femoral artery but the distal popliteal remained occluded.

The popliteal in the left leg (left side of photograph) ends just below the knee. A calcified superficial femoral is seen in the right leg (Right side of photograph). His toes were noted to be cool postoperatively while his thigh was warmer. His postoperative course was complicated by a heparin-induced thrombocytopenia manifested by widespread ecchymoses of his thigh and scrotum. Coumadin was started and platelets administered.

On the 24th hospital day, his leg was again found to be cold and another arteriogram and embolectomy were performed. Again, his femoral was found to be obstructed in its mid portion. However, on this occasion his leg remained cold after "embolectomy" and no popliteal pulse was demonstrable

He was referred for boot therapy on his 25th hospital day, August 21st, 1980. His leg was now very painful and merely introducing his leg into the boot was an ordeal. An attempt was made to give him an intensive course of boot therapy. His leg was comfortable on some occasions while on others his thigh was especially painful. He and his vascular surgeon saw no immediate benefit after a few days. He underwent an above-the-knee amputation.

Comments: This case is to be compared with the previous one. His whole course might have been favorably altered if he had been booted on admission when his "cool" leg was first noted. The year was 1980 and early coronary angiography and angioplasties were not in vogue. It is 2004 now and they are. Today, he might likely have a catheter placed through his calcified femoral arteries exposing him to other complications (bleeding, peripheral emboli etc.). A trial of boot therapy is obviously safer, quicker and cheaper. If it proves ineffective, one can always be more aggressive.