Case 16: Salvage of Patient and Legs after Massive Thromboembolism and Aorto-iliac Surgery

This 68 year old man with type 2 diabetes was admitted to the hospital because of emboli to his legs. His arteriogram (first photograph) revealed diseased iliac arteries, an occlusion in the right superficial femoral artery and (second photographs) single runoff down the posterior tibial artery in the right leg. Distally, the tibial vessels were not well seen in the left leg.

(1) Diseased Iliac Arteries (left) and Superficial Femoral Arteries(right)

(2) Bilateral Tibial Occlusive Disease

Following replacement of his lower aorta and iliac arteries, he was found to have occluded his major vessels in both legs. Embolectomies and heparin were ineffective in restoring arterial blood flow. Sunday afternoon his legs were mottled (third photograph), cool and paralyzed. His ankle/arm blood pressure ratios were zero. He was toxic and had elevations of his white count and his serum transaminases. A portion of his scrotum was infarcted (fourth photograph).

(3) Cool, Mottled and Paralyzed Legs at Time of Boot Referral

(4) Infarcted Scrotum

The possibility of bilateral high leg amputations was considered. He spent the greater part of Sunday night, Monday and Monday night in the boot. By Tuesday morning, only his feet and a spot above his left ankle were devitalized (fifth photograph).

(5) Tuesday, After 1.5 Days Booting

(6) Two Weeks and Pretty Much Normal above the Toes

He continued to receive multiple treatments daily. After two weeks, his right first and third toes and his left distal foot were devitalized (sixth photograph) After almost two months of treatment, only the distal portions of his left toes were dead( seventh photograph).

(7) Toes Now Well Demarcated

Rather than await a spontaneous autoamputation, he chose to have the necrotic areas of his left toes surgically amputated to hasten his return to work (eighth photograph).

(8) Left Foot Healed and Right First Toe Tip Autoamputating

Comments:Boot therapy appeared to have saved this man from high bilateral leg amputations. He was not a candidate for other therapies. Heparin and embolectomies had failed. Fibrinolysin infusions were contraindicated in view of his recent major surgery. He was lost to follow-up after his toes were amputated and died 15 months later..