Case 15: Amputation Avoided and an Example of Vascular Tests

This 75 year old engineer had had diabetes 22 years. It was initially treated with oral hypoglycemic agents. Over the last few years, he had taken insulin. He had angina for thirteen years. He presented for boot therapy with a two month history of rest pain in the right foot. An arteriogram was done in his community hospital and revealed no major vessels below the popliteals; only a few twigs of arteries were seen in the left upper calf.

Flow Ending Below the Upper (right leg) and Lower (left leg) Popliteal Areas

Nonvisualization in Lower Two-Thirds of Both Legs

A sympathectomy was performed; he has continued to have paresthesias in his foot which he attributes to this operation. Persistent pain led him to seek another opinion at an academic center in Philadelphia. Another arteriogram revealed again no possibility for vascular surgery. His ankle blood pressure was a questionable 20 mm Hg. Leg amputation was suggested. In response to his direct question about alternative forms of treatment, treatment with the Circulator Boot on the medical service at the Center was suggested and initiated. When he learned that the inventor of the Circulator Boot was at Bryn Mawr, he requested transfer to the Bryn Mawr Hospital where he arrived with focal black areas of necrosis on his middle three toes and ankle blood pressures of 42 mm Hg in the posterior tibial and 0 mm Hg in the anterior tibial and peroneal arteries at the ankle.

Ruborous Foot with Focal Necrosis of Three Toes on Presentation to Bryn Mawr

Less Rubor but Progressive Necrosis

Blood flow, of course, must be restored to the calf before it is restored to the ankle, to the ankle before to the midfoot and to the midfoot before the toes. During this process, his foot color slowly improved while initially his toes worsened. When his pain was tolerable, he was discharged with a Mini-Boot which he applied to himself at work. His pain and numbness disappeared. The distal portion of his third toe progressed from the original purple to dry gangrene, autoamputated and healed. The second toe healed beneath the area of superficial gangrene. Only the paresthesias remained from his sympathectomy. He was fully ambulatory and traveled abroad on business.

Foot at Two Months

Followup at One Year

Baseline Doppler Studies at the Anterior Tibial, Posterior Tibial and Peroneal Arteries (top left); Baseline Electric Oscillometry at the Midthigh, Midcalf and Ankle (bottom left); Doppler Studies at Six Months at the Anterior Tibial, Posterior Tibial, Peroneal, 1st Dorsal Metatarsal and 2nd Metatarsal arteries (upper right); and Electronic Oscillometry at the Ankle at Six Months

Comments: As an engineer, this man was sufficiently sophisticated to take the boot home and treat himself properly His vascular tests documented the improvement in blood flow suggested b the appearance of his feet. He treated both legs and both legs did quite well... when leaders in the vascular surgery world had wanted to take his legs off. The improvement in his Doppler waveforms here are better than we usually encounter... and are better than are needed for healing. He developed relatively narrow waveforms with sharp upstrokes. Most patients increase the amplitude of their waveforms with less narrowing.