Case 20: Expectant Care but Leg, Heart and Patient Do Well

This 84 year old type 2 diabetic female was referred by her University vascular surgeon who considered her inoperable because of a lack of saphenous veins which had previously been used for coronary bypasses, anginal decubitus, mild congestive heart failure and emotional lability attributed to a previous small stroke. At the time of presentation for boot therapy, she had had a history of one half block claudication for five years, a three month indoor walking limit of a few steps, an ankle/arm blood pressure index of zero, no benefit from recent iliac and superficial femoral artery angioplasty procedures and leg ulcers not healing over a three month hospitalization in spite of whirlpool treatments, intravenous antibiotics and frequent dressing changes. While the dilatation of her iliac appeared to have no benefit on her leg ulcer, it did improve inflow into her upper thigh and made her a reasonable candidate for boot therapy

Ulcerated Anterior Right Shin on Presentation

Ulcerated Lateral and Posterior Leg on Presentation

Boot therapy was commenced in the Bryn Mawr Hospital and shortly thereafter continued in a nearby nursing home. The treatments were not easily performed because of complaints of pain and abundant tears. It was noted, however, that she might also cry if her orange juice was not cold. Her program on a typical day in the nursing home included: (1) two Mini-Boot treatments with wet-to dry dressings containing Sea Soaks and appropriate antibiotics over her lesions; (2) two Long-Boot treatments again with wet-to-dry dressings; and (3) appropriate oral antibiotics. Her legs healed slowly. Her dypsnea and angina abated. A slight knee contracture marred an otherwise perfect result and limited her ambulation. Her family had sold her home and left her in the nursing home expecting her to die. She fooled them all and did well.

Looking for a Lesion, the Photographer Takes the Wrong Side of the Leg

Comments: In this case, boot therapy was associated with an overall improvement in the vascular status of the patient. Other cardiac-assist boots would have been contraindicated; they aggravate peripheral arterial disease by using higher compression pressures (which expel arterial blood from the leg) and by allowing less time for the individual pulse waves to enter the leg. The Circulator Boot attempts to maximize the inflow time by its end-diastolic pumping and its capacity to pump after each, every other or every third heartbeat as desired by the physician. The angina and the congestive failure of this lady disappeared. At present, we are following the cardiac benefits of booting such patients with the IQ heart monitor (an electrical impedance apparatus which allows us to monitor cardiac output, stroke volume and the ejection fraction noninvasively during boot therapy. Again, other pneumatic leg compression devices that are not cardiac-synchronous and which compress for several heartbeats at a time would have been contraindicated. Such devices would have impeded inflow into the leg during their inflation periods and would have required minutes between inflations to allow her ischemic leg to refill with blood. Indeed, we are referred each year a few patients who have developed lesions after the use of such boots. There are boots and boots.... but only one Circulator Boot System.