Case 145: Boot Therapy Improves Vascular Tests and Prepares Way for Successful Bypass Surgery

This 63 year old male had a long history of arteriosclerotic cardiovascular disease promoted by smoking, hyperlipidemia, hypertension and glucose intolerance. He presented with rest pain in his toes, a persistent soreness in his metatarsal area, tender cracks in his heels and 1.5 block claudication. His outside arteriograms showed an occluded deep femoral artery, an occluded superficial femoral at the mid-thigh, no popliteal artery, and a reconstituted distal posterior tibial artery which had poor runoff at the ankle and was thought to be inadequate to accept a bypass graft. After two weeks of booting, his toe pain was gone and he was able to walk 3-4 blocks, but he still had a numbness in the area of his metatarsals. After three months of booting, his Doppler studies showed an increase in his ankle/arm index from 27% to 46% and the height of the Doppler writeout increased from 10 mm to 37 mm. His referring university vascular specialist noted an improvement in his vasodilatation tests with the toe temperatures rising as follows: 1st toe 26.6 degrees C to 28.0 degrees C, 2nd toe 25.2 degrees C to 27.3 degrees C, 3rd toe 25.6 degrees C to 27.1 degrees C and 4th toe 26.8 degrees C to 28.1degrees C while there was a 0.2 degree C drop in the 5th toe. He was clearly getting better. Unfortunately, however, he developed an allergic reaction to the skin creams he was using on his instep where he developed some infected blisters. Concern about the latter led to repeat arteriograms to re-examine the opportunity for bypass surgery.

His baseline arteriogram is seen on the right. The arteriogram on the left shows both legs after 4 months of outpatient boot therapy (40 minutes 4-5 days a week). New collateral vessels are seen in the calf and the posterior tibial is better visualized distally.

Runoff is seen into the foot that was not present in his baseline study.

A first attempt at bypass was unsuccessful at the university center. He returned to Bryn Mawr for more booting. Our surgeons thought a second attempt was worthwhile and did successfully bypass into his posterior tibial. He stopped smoking and has done well.

Comments: This man developed new collaterals around his obstructive vascular lesions and he recovered flow in a distal vessel that previously did not visualize on his arteriograms. It is likely that clot and sludge-like material was mobilized from the distal vessel. The outline of the vessel, once cleared, actually looks smooth and healthy.