Case 154: Rehabilitation of Both Legs in Buerger's Disease Patient Who Stops Smoking

This 59 year old male smoker had a mesenteric thrombosis 4 years prior to his current hospital admission. Eight months prior to admission, he had 75 foot claudication leading to his first Bryn Mawr admission for arteriography.

His vessels were normal in the groin and upper thigh.

Likewise the lower superficial femoral and popliteal were normal. However, just distal to the takeoff of the anterior tibial artery, there was complete occlusion of the right posterior tibial and peroneal arteries.

In the right leg, the lower half of the posterior tibial and peroneal were visualized from collateralization. The lower half of the anterior tibial was occluded. In the left leg, all three tibial vessels were occluded below the mid-calf..

He was ordered to stop smoking and given a prescription for Vasodilan. The status of his feet continued to deteriorate over the next six months and he developed multiple painful ulcerations on both feet.

Feet on presentation for boot.

All walking was very painful.

His vascular surgeon had no suggestions. His family doctor referred him for boot therapy. He was treated for a few days as an outpatient and then, as he was still smoking and found getting to the office difficult, he was hospitalized for two weeks. His non-invasive vascular testing documented the findings of his arteriogram and his response to boot therapy.

The Doppler velocity waveform of the left superficial femoral was tall, narrow and biphasic.

The right superficial femoral was wider and lower.

The left popliteal likewise was normal in being tall, narrow and biphasic.

The right popliteal was low and wider.

Beneath the popliteal, the waveforms became wider and lower . Here at the foot and ankle, the tracings are grossly abnormal... low and wide... but still there.

Doppler sounds were barely audible on the dorsum of the right foot. In comparison to the ankle pressures shown, his arm blood pressure was 145/94.

The pulse volume curves of the left thigh and calf were larger than those of the right leg.

At the ankle level, the pulse volumes were very low in both legs, especially the left.

With his treatments, his pain disappeared, his ulcers healed, his walking capacity improved and his overall skin texture improved.

His non-invasive vascular tests also improved. Here are shown the tests at the ankle level for the left leg one week after hospital discharge.

The improvement in the right leg was also sustained. His arm blood pressure was 134/88 supine.

He could not be more pleased. He took a vacation trout fishing and did well. Unfortunately, he started to smoke again and returned to the boot clinic several months later again with claudication and foot pain. He was pumped out in the clinic and did well over the next several years before he was lost to follow-up..

Comments: This another old case but he illustrates several things. On his previous course, he was at risk of bilateral leg amputations. He did well after his course of boot treatment until he resumed smoking. Then he was treated successfully again. Such is the case with such patients. Their long term success is dependent on their stopping smoking. His non-invasive vascular tests are also interesting. They showed differences between the legs at the level of the thighs and knees that were consistent and not reasonably explained by the arteriograms. The latter, of course, were done earlier and the differences may have been due to progressive disease. Still, the noninvasive tests are dynamic tests while the arteriogram merely demonstrates a puddle of dye. Historically, we used to follow our patients with periodic vascular tests to help determine their therapeutic needs. Today's HMO does not allow serial testing and commonly requires that all vascular tests be performed in a capitated site by persons who are unaware of the history, needs and therapeutic options of the patient. The need for a debilitated patient to travel to such sites, of course, discourages many from getting necessary tests... and, in the short term, saves the HMO money.