Case 146: Boot and Bypass Salvage Leg and Ambulatory State until Death

This 80 year old male diabetic smoker had a brief episode of congestive heart failure after his first leg vascular procedures: an embolectomy and a femoropopliteal Gortex bypass graft in May 1983. He was discharged with diagnoses of left superficial femoral artery occlusion, left femoral bypass occlusion and embolectomy. On October 3rd, 1983 he underwent another embolectomy and had an angioplasty of a left superficial femoral artery and femoral bypass occlusion under spinal anesthesia. On October 4th, a thrombectomy was again performed in an attempt to keep his graft open. In February 1984, another arteriogram was performed and thought to show no vessel or runoff to allow further surgery. Leg amputation was advised.

The left superficial femoral was totally obstructed high in the thigh (left). A few small collateral vessels were seen in the thigh down to the knee.

In the lower left leg, only scattered small vessels were seen. There was no continuous flow down any of the right tibial vessels either.

Except for an one inch segment in the instep and another in the heel, delayed films showed no vessels in the foot.

He was referred to Bryn Mawr for boot therapy on March 9th, 1984. He came for outpatient treatments over the next year. His vascular tests improved and declined: the blood pressure/height of the Doppler writeout increased from 83/15 in the posterior tibial and 37/5 in the anterior tibial to highs of 96/24 and 63/17 respectively. His peak values were obtained after periods of intense booting. His pain in his calf and foot had been relieved but an ulcer on the end of his left big toe had defied all therapy. A small lesion on the right foot, on the other hand, responded quickly to therapy in July 1984. He was hospitalized in Bryn Mawr in later October 1984 for another arteriogram. Our vascular surgeons offered him a 30-50% chance of an effective successful bypass. He chose to continue booting .

The October 1984 arteriogram again showed an occluded superficial femoral.

Additional collaterals had developed around the knee.

The peroneal reconstituted in its distal half. In the lower left leg, only scattered small vessels were seen. There was no continuous flow down any of the right tibial vessels either.

The arteriograms showed no patent proximal tibial vessel. Both the plantar and dorsal arches were well visualized on delayed films. Segments of the anterior tibial and posterior tibial were seen distally. While his leg was symptomaticly greatly improved, his toe lesion remained a problem. On the basis of the findings in his October arteriogram and the persistence of Doppler sounds in his posterior tibial artery, he was readmitted to Bryn Mawr on April 12th, 1985 and a composite bypass was performed using a vein in-situ and a vein from his right leg. His leg did well and he remained ambulatory until his death at home December 29th, 1985.

Comments: This man like the previous man developed sufficient distal flow to allow another bypass. His leg was maintained by booting long after his home surgeons had recommended amputation. His changes in his vascular tests were disappointing. One wonders if we will find that smoking decreases the elaboration or effectiveness of angiogenic growth factors. Like our other patients with serial arteriograms, he was a overall boot failure in that surgery was still necessary. Successful boot patients do not volunteer for serial arteriograms. In this patient, a medical approach and a surgical approach together saved his leg. Unfortunately, various specialties may view one another as competitors and not cooperate. Cooperation does work. On August 25th, 1987 the "National Enquirer" carried a story on the Circulator Boot (Doomed Legs Saved etc.). For a few months we had people descending on Bryn Mawr from all over North America. They came with advanced inoperable disease hoping for a quick cure. We pumped on several a week or so, noted an improvement in their Doppler studies, repeated their arteriograms and successfully bypassed their legs.