Case 150: High Risk, Boot Therapy, Bypass Surgery and Death in the Hospital Corridor

This 80 year old female diabetic presented with a seven year history of increasing claudication in the right leg. At the time of admission to the vascular surgery service, she complained of coldness and numbness in her foot, of a small paronychia and, after walking but a few yards, of severe pain in her calf. Her medical consultants noted an ischemic cardiomyopathy and episodic congestive heart failure. Obesity, diabetes and hyperlipidemia (cholesterol 278 and triglycerides 429) were documented risk factors promoting her vascular disease. With the thought of postponing vascular surgery until her condition was stable, her surgeon referred her for boot therapy. Her response to the boot therapy was disappointing; one day she might walk the hospital floors without difficulty and the next day she found walking to the bathroom difficult. She was a difficult patient to treat: her leg had to be positioned to her liking in the boot and the bed adjusted just right. From time to time, she had anxiety attacks in her hospital room that may have represented angina. Still her vascular tests slowly improved. Blood pressure was followed at the ankle in the anterior tibial (AT) and posterior tibial (PT) and the height of the writeout was recorded for the Dopplers in both vessels and for the pulse volume at the ankle:

The arteriogram showed multiple stenotic areas in her right superficial femoral artery. The proximal left superficial femoral was lost and long thin stenoses separated segments of the vessel in the distal half of the thigh. Multiple collateral vessels had developed especially in the right leg.

The surgeon first performed a profundoplasty. As the vascular tests show above, the procedure provided minimal benefit. Indeed, she developed leg pain again a few weeks later and was readmitted to the hospital when her arteriogram showed that her right superficial was occluded. On this occasion a boot consultation was not requested. A femorotibial bypass was planned but had to be postponed twice because of chest pain and possible congestive heart failure. The procedure was eventually successfully carried out and she was discharged from the hospital presumably benefited. On the way home from the hospital, she attempted to walk from her car to a restaurant and experienced an episode of shortness of breath and chest pain. Her frightened family immediately brought her back to the hospital to arrange for nursing home care. Again she had an anxiety attack at the prospect of becoming a nursing home resident. She had a cardiorespiratory arrest and was only transiently resuscitated. She died in the hospital corridor on the way to coronary care.

Comments: Not discussed above was the mental status of this lady. She was described by some as senile and anxious. Her age, history of congestive failure and her mental status were factors in the decision not to consider coronary bypass. One might ask what were proper goals in treating this woman. A perfect leg bypass was not likely to alter her life style. Her activity was still going to be limited by her coronary disease. She was a high risk surgical patient. She likely would have chosen outpatient boot therapy if her other physicians had advised her it was her best course. The Long-Boot is a cardiac-assist device and may help compensate patients with significant cardiac impairments... but not necessarily sufficiently to guarantee their safe passage through major surgery.