Case 137: Production of Runoff for Bypass and Restoration of Flow in Occluded Graft

This 78 year old man was an insulin-dependent diabetic and a former smoker. He had been referred a year earlier by his orthopedic surgeon for a non-healing ulcer of his right big toe; it healed nicely with out-patient Circulator Boot treatments. He was admitted now on February 11th, 1980 with arterial insufficiency of his left leg. He had noted soreness in his left calf aggravated by walking and had sought the care of his masseuse. Two days before admission, his symptoms pointed to a worsening of his arterial disease: his leg became weak, he fell and he had severe pain in the calf which his family doctor interpreted as a severe bruise. The day prior to admission, the patient felt that he had had a severe stroke: the lower 25% of his leg was numb and paralyzed, his calf was extremely tender, and the leg was cold below the knee.

His left foot showed rubor only after prolonged dependency.

His foot became lard white with slight elevation.

His vascular tests showed good Doppler sounds to the mid-thigh but no vascular sounds were found below the tibial tuberosity, the silence an ominous sign suggesting that an arteriogram at this time would show no runoff. Long-Boot treatment was started and was associated with a rare problem: claustrophobia in the boot making the full forty minute treatment difficult. Except for the latter, the treatment was tolerated well. He was given 4 to 6 shorter treatments daily. At the end of the first week, his calf was soft and pain-free while his foot had recovered pain sensation on palpation. His foot was noted to be warm about the 8th day. His need for many small treatments taxed the boot staff and when his tests documented the presence of runoff in his leg an arteriogram was accomplished.

On the left are his admission vascular tests of his distal leg; the pulse volume and Doppler tracings were flat at the ankle. In the center, Doppler waveforms were shown in the anterior and posterior tibial vessels at the ankle just prior to his arteriogram. On the right, improved, but not normal, waveforms were seen after successful femoral-peroneal artery bypass surgery and his transfer to the vascular surgery service.

His arteriogram showed a complete blockage of his superficial femoral artery from his lower portion through the popliteal artery. Multiple collateral vessels were seen around the knee and in the calf. The peroneal and tibial arteries were visualized but showed multiple areas of stenosis and obstruction. As seen above, his vascular tests were improved after his bypass but his foot pain persisted over his three week postoperative hospital period.

After discharge, he returned to the boot clinic seeking relief from his persistent foot pain. The latter along with hopes of maintaining the patency of his bypass and further improving collateral flow down the leg should the bypass be lost were also considerations in restarting his therapy. His pain was relieved. He was discharged and he resumed his usual life style, which, unfortunately did not include tight control of his diabetes (glycohemoglobin 10.3%).

A month later he had a stroke infarcting his right fronto-parietal area and developing a left hemiparesis. He saw his cardiologist for intermittent atrial fibrillation. On a Sunday, in late August 1980, he awoke from a nap with a numb left leg. His chauffeur brought him to the boot clinic where Doppler testing again revealed a quiet lower leg. Boot therapy was immediately resumed with return of his previous Doppler pulses. He then became an intermittent boot patient coming for therapy whenever he noted his legs were unusually cool or uncomfortable. He was maintained on coumadin therapy which, unfortunately, was associated with a gastrointestinal bleeding episode in June of 1981. He had another massive stroke in August 1985 and moved to a nursing home. As he failed and became totally bedridden his legs developed decubiti and booting was resumed in the nursing home. He died from a massive myocardial infarction on September 13th, 1986. He still had both legs.

Comments: This man had various small foot lesions that responded to short courses of boot treatment but his major ischemic episodes are perhaps the most interesting for the vascular surgeon. Booting appeared to create the runoff that allowed his bypass. Booting relieved his persistent postoperative pain (it might have gotten better anyhow if it represented a resolving ischemic neuritis). Booting restored his bypass when it occluded. And booting helped maintain his legs until he died. He was not admitted for an embolectomy after his graft occlusion. We have no data as to how often we can restore flow in an acutely occluded graft as we rarely are referred such cases by their vascular surgeons who favor embolectomy. This man fortunately opened up after a single treatment. In others, who had a longer duration of their occlusion and did not acutely open up, we have combined intravenous streptokinase therapy with booting.