Case 138: Production of Collateral Flow. Dopplers and Arteriograms.

This 60 year old female smoker was admitted on the Bryn Mawr Hospital Vascular Surgery Service on October 13th, 1980 with a pale cold right leg and a three month history of rest pain. The foot was cyanotic on dependency and the big toe was especially discolored. Her past medical history included bilateral mastectomies for breast cancer, three thrombectomies and endarterectomies of the left femoral artery, and a left beneath-the-knee amputation. On October 14th, she had the arteriogram shown on the left below.

The distal half of her superficial femoral and her popliteal were occluded. A few small vessels and the medial geniculate artery were seen. Essentially, no flow was seen below the knee.

Vascular testing on October 21st revealed faint Doppler signals in the posterior tibial at the ankle and flat pulse volume curves at the calf and ankle.

A sympathectomy was performed without any effect. Her continued smoking in the hospital was of no benefit. On the 21st of October she was referred for boot therapy. Her leg was cold and extremely painful. She required frequent narcotic injections both during and between boot therapies. After four days of treatment, the discoloration in the distal foot was reduced but severe pain persisted... again commonly leading her to smoke to relieve her "nerves". Her vascular surgeon ordered a repeat arteriogram on October 29th. We had pumped on a similar leg for the surgeon several weeks earlier and had also improved the color of that leg. He had repeated the arteriogram in that patient and found a vessel he successfully bypassed. So was his hope here.

New small vessels were seen around the knee. The new vessels were especially prominent in the calf. The peroneal artery was visualized. A few very small vessels wee seen over the 4th and 5th metatarsals but no flow was seen in the rest of the foot.

She was booted a few more days and her vascular testing was repeated on November 2nd. Faint pulse volume oscillations were seen at the calf and ankle. Measurable Doppler tracings were found in the posterior tibial and peroneal arteries at the ankle.

She had received ten days of boot therapy and was showing signs of improvement. Her vascular surgeon offered her the options of (1) an attempted bypass into her distal peroneal artery, (2) an immediate below-the-knee amputation or (3) more boot treatment. She chose the attempted bypass, which proved to be impossible and led to the leg amputation. Postoperatively, her stump proved hard to heal.

Comments: Ten days of booting produced some collateral flow and improvement in her clinical status. It was 1980. We were subsequently to learn that most patients with this degree of ischemia require many more treatments to achieve maximal results. This lady was not a success. She continued to smoke after discharge and likely would not have done well in the long run even if her bypass had been a success. She is shown here to point out that a short course of booting is not a cure-all. The development of her collateral flow is interesting and worthwhile calling to the reader's attention, however. We commonly see the development of such flow after booting. In the "Clotting and Vascular Hormone" section of our library, the reader will find that booting stimulates the release of fibrinolysins, nitric oxide and prostacyclin. Unsuccessful cases like this one are our sources of arteriograms. We find few successful cases will volunteer to repeat an arteriogram if it is not necessary.