Case 194: Dialysis Avoided, Congestive Heart Failure Improved and Legs Preserved with in Patient with Ischemic Neuropathic Foot Ulcers

Both feet were intensely ruborous in the dependent position. There were areas of focal necrosis/black eschar on his right heel, on all 5 right toes (especially 1,3,5), on spot on the dorsum of his right foot over his 4th metatarsal head and on the ends of the left 2nd and 3rd toes, above the left internal malleolus and on his left heel.

This 69 year old New Yorker presented in Bryn Mawr on December 28th, 1998. He had had diabetes for 15 years that had been treated with Glucatrol XL and in recent months Rezulin. His sugars were not well controlled. Insulin therapy had been started in the preceding few weeks in recognition of his vascular and neuropathic complications. His New York specialists noted he had calcific distal occlusive disease in his legs and significant heart disease. An echocardiogram on October 21st, 1998 showed global hypokinesis, inferior and apical akinesis and an estimated left ventricular ejection fraction of 40%. On December 10th, 1998 they noted he had developed some black eschar on the dorsum of his right big toe and had one block claudication. Trental was prescribed. Because multiple areas of breakdown were developing on both feet and the vascular center in New York had nothing to offer, he came to Bryn Mawr on December 28th.

His home sugar record showed his diabetes was still poorly regulated: his sugars generally ranged from 200 to 300 mg/dl. His recent blood tests included a bilibubin 1.4 mg/dl, BUN 121, creatinine 2.9 mg/dl and hemoglobin 10.4 G/dl. He weighed 195 pounds. His blood pressure was 112/70 mm Hg supine and 95/60 sitting. He had bilateral retinal hemorrhages. His nose and fingertips were cyanotic. His cheeks and chin were ruborous. His right chest was dull on percussion. His neck veins were distended with the examining table raised to a 40 degree angle. He had a faint right carotid bruit. His femoral pulses were 2+ bilaterally, the right popliteal pulse 2+ and the left absent while the distal pulses were all absent. He was unable to discern the vibrations of the Bio-thesiometer with the voltage turned up to the maximal power of the apparatus (over 50 volts).

His pulse volume curves decreased progressively down both legs and were essentially flat in the right mid-foot and very low in the left mid-foot.

His Doppler sounds were faint and monophasic at the ankle level and absent in both feet. RPT = right posterior tibial, RAT = right anterior tibial, R1stDMA = right 1st dorsal metatarsal, LPT = left posterior tibial (pressure 85), LAT = left anterior tibial (pressure 185) and L1stMTA = left 1st metatarsal artery.

Over the holidays, he had no therapy and did not do well. He was subsequently admitted to the Bryn Mawr Hospital on January 2nd because of weakness, falls, urinary incontinence, pain in his feet and 3 pillow-orthopnea. His list of medical problems included chronic pulmonary disease associated with a 30 pack-year history of smoking; his diabetes complicated by retinopathy, nephropathy, peripheral neuropathy, hypertension, arteriosclerotic cardiomyopathy, congestive heart failure and histories of having had a cholestectomy, kidney stones and sialoadenitis. His admission laboratory data included: BUN 125 mg/dl, creatinine 2.4 mg/dl, albumin 2.6 G/dl and 2+ proteinuria. His chest x-ray showed a large heart and pleural effusions. Intravenous antibiotics (Unasyn) were begun because of his painful infected feet but were discontinued the 3rd hospital day because of their solute burden on the kidney and a rise of the BUN to 137 mg/dl (dialysis had been offered to the patient and refused). Antibiotics were injected into his feet and added to the Sea Soak solutions used in the Mini-Boot. The patient began a routine of Long-Boot treatments to both legs (to support his heart and kidneys), cleansing foot soaks in Sea Soaks and Mini-Boot treatments with his feet immersed in Sea Soaks containing appropriate antibiotics. He improved and requested to be discharged from the hospital. He had been in too many hospitals and was anxious to leave. He was discharged, hence, on January 9th, 1999 to live at the house of a son who lived nearby. He was now walking unfortunately too well. He was advised to minimize ambulation lest he further damage his feet. His discharge medical program included: Tenormin 25 mg/d, Pepcid 20 mg/d, Lasix 80 mg/d, Dilaudid 4mg as needed for pain, both Long- and Mini-Boot therapies to be given in the outpatient boot clinic in the morning and afternoon with Urecholine and Fortaz to be added to the Sea Soaks in the Mini-Boot, a 50 gram protein 1800 calorie diet and an aggressive insulin program. He was to continue taking 14 units of NPH insulin at bedtime and to test his blood glucose level before each meal and bedtime. He was to take a Humalog insulin scale for the glucose levels <60, 61-90, 91-120, 121-180, 181-240, 241-400 and >400 respectively as follows: at breakfast 0,4,7,8,10,12 and 14; at lunch 0,4,5,6,8,10 and 12; at supper 0,6,8,10,12,14 and 15; and at bedtime S,s,0,0,2,4 and 5 where "S" is a 30-gram carbohydrate snack and "s" is a 10-gram snack.

He continued with his outpatient treatments throughout the spring and early summer. His overall health status slowly improved. His facial cyanosis and rubor disappeared. His heart failure improved as did his laboratory values: on January 12th... BUN 113 and creatinine 2.9 mg/dl; on January 29th... BUN 61 mg/dl, creatinine 2.5 mg/dl, albumin 3.2 G/dl, hemoglobin 10.6 G/dl and hemoglobin A1C 7.6%; and on February 13th... BUN 60 mg/dl and creatinine 2.4 mg/dl. In the meantime, the color of his feet had improved and his pain diminished while some lesions healed and others enlarged.

The lesions on his left toes had healed but he had developed a small bunion ulcer.

The eschar on his left heel had increased in size.

The lesions on right his toes were demarcating.

And the eschar on his right heel had increased in size.

His laboratory tests continued to do well: March 22nd... BUN 58 mg/dl, creatinine 2.1 mg/dl, albumin 3.1 G/dl and hemoglobin 11.4G/dl (he was also receiving erythropoietin); and on April 30th... BUN 65 mg/dl and creatinine 2.1 mg/dl, albumin 3.4 G/dl and hemoglobin A1C 7.7%. In May, a heavy growth of yeast was recovered form his right foot (Fungizone was, hence, added to his Mini-Boot solutions). In June, his chest x-ray showed a near normal heart shadow but a persistence of some right pleural fluid. In July, a light growth of yeast and some Corynebacterium were recovered from his foot. In July, he saw his New York cardiologist who expressed pleasure at finding his heart smaller.

The dead portions of the toes were autoamputating. The skin color was further improved.

And the eschar on his right heel was beginning to close in.

The floor of his left bunion ulcer was close to healed on September 27th.

As was the left heel ulcer.

On August 25th, 1999, he was readmitted to the hospital with an aggressive necrotizing cellulitis of his distal right foot due to a Staphylococcus aureus that was sensitive only to vancomycin. He was to stay until September 17th. His admission laboratory data included BUN 80mg/dl, creatinine 3.7mg/dl, albumin 2.6 G/dl and hemoglobin 9.6 G/dl. His pulse volume studies were repeated and noted to have improved over the studies he had in December 1999.

Note that the mid-foot scale is now 0.0 to 0.4 instead of 0.0 to 0.2 mmHg. While the values have improved at all levels of both legs, the flow remained poor in the feet.

His Doppler waveforms were broad and low at the left popliteal (L-POP) and right popliteal (R-POP). Broad low waveforms were found at the right posterior tibial (R-PT) and in what was thought to be a collateral from the right peroneal to the right anterior tibial at the ankle (RATC). Faint flow was heard in the right 1st dorsal metatarsal artery but no good waveform could be recorded (R1stDM). While his studies were improved, they remained significantly abnormal. Could he benefit from a surgical bypass procedure?

He required regular Percocet medication for the relief of the pain associated with his infection and his alertness and intake of food and drink suffered. Serial renal function testes showed a rise in his BUN's (78(9/5),80,88,89,85,79,85,92,97(9/28) and corresponding creatinines: 3.6,3.6,4.6,4.6,4.5,4.3,4.6,4.7,4.4.mg/dl). An MRA on September 9th showed complete occlusion of his right distal popliteal and posterior tibial arteries while the anterior tibial and peroneal arteries were visualized. The left popliteal artery was patent but there was runoff only down the left anterior tibial which had stenoses at both ends. His right saphenous vein was patent raising the possibility of a distal bypass revascularization procedure, which, however, was thought to be too risky for him in view of his cardiopulmonary and renal status. He was discharged from the hospital to the Transient Care Unit where he stayed from September 17th to October 7th, 1999. Laboratory values on September 17th included: albumin 3.0 G/dl, an elevated Cpk, BUN 105 and creatinine 4.9. He received Long- and Mini-Boot therapy twice a day during his stay in the TCU and his BUN dropped to 76mg/dl and his creatinine to 3.2mg/dl.

With local injections of Vancomycin into his distal foot and his Mini-Boot and Long-Boot treatments, the infection quieted down and his foot became stable. On October 7th, he was discharged to his home taking: Epogen three days a week, Atenolol 25mg daily, aspirin, Phoslo, Lasix 60 mg daily and Aldactone 25 mg daily. He was scheduled to continue his daily boot treatments.

He was not to make his daily treatments, however. He was still taking Percocet for pain and became anxious and confused. He had a supply of Valium for anxiety which he began to take and his confusion worsened leading to another hospitalization for his change in mental status from October 19th to October 31st. His admission studies now included an EKG showing right bundle branch block, 1st degree AV block and a possible non-transmural myocardial infarction. Other abnormalities included blood PO2 62, serum potassium 7.1 mEq/L, an elevated CpK and a chest x-ray showing cardiomegaly, a right pleural effusion and likely congestive heart failure. The CT scan of his head showed brain atrophy beyond his years. With his boot therapy, he gradually improved and his BUN and creatinine again dropped. On October 29th, he had BUN 76 and creatinine 3.2mg/dl. He was reasonably free of fluid and weighed 183 pounds on October 31st at the time of discharge. His discharge medications now included: Imdur 60 mg/d, sodium bicarbonate 650mg/d, Pepcid 20 mg/d, Lasix 60 mg on alternate days, Epogen 4000 units 3x/week, Apresoline 20 mg four times/d, Kayexalate 30 grams on alternate days, Coreg 3.25 twice daily, aspirin 325 mg/d and his multidose Insulin program. He returned to his New York hospital for a review of his status. His physicians there attempted a right transmetatarsal amputation which, his son reported did well. He was discharged home but, his son reported, lost energy and desire and died on December 22nd, 1999.

Comments:This man was at risk of losing two legs. One did well and the other remained a problem until he had his transmetatarsal amputation. He lost neither leg. He also had advanced heart disease and renal failure. He was a candidate for dialysis but, as the nephrologist commented, dialysis cannot restore a damaged heart. Treatment with the Long-Boot did improve his heart function and, perhaps secondarily, his renal function. He had been advised that in such patients, the effect of booting on the heart is transient lasting about three days. His foot ulcers provided justification to Medicare for his pumping and while he was pumped his heart and kidney function improved. When he went elsewhere for his foot surgery, his heart and kidneys again failed and he lost desire for life. He is presented more to illustrate the effect of booting on his heart and renal function than to claim great benefit for his feet. The transient benefit on heart function should be appreciated. We have tried to add small doses of growth hormone in some of these patients with as of yet unknown benefit. It is not uncommon for consultants, who are unfamiliar with the effects of the Circulator Boot, to over-estimate the cardiovascular health of these patients and recommend procedures in other institutions that prove to be excessive.