Case 200: An Example of Stabilizing a Difficult Situation and Comfort Care Along with Assorted Other Patients to End Our Series

Case 200a: At age 67 this man was admitted on August 24th, 1998 to an academic center in Philadelphia with rest pain and infection in his right lower leg. He had a history of scleroderma, hypertension, congestive heart failure, emphysema, and, in 1992, femoral-popliteal bypasses in each leg. His admission medications included Cuprimine, Zantac, Lasix, digoxin, Cardizem, Cozaar, Tylenol, propoxyphene and Trental. He complained of shortness of breath, chest pain, decreased exercise tolerance and constipation. Pain and a right foot ulcer that had not healed over the past few months had led to his admission. On August 25th, 1998 a profunda endarterectomy with a vein patch angioplasty was performed along with a femoral-peroneal bypass with a non-reversed saphenous vein. On the first postoperative day, he had several episodes of ventricular tachycardia that resolved spontaneously. He was readmitted in December when his arteriograms showed mild narrowing of the native peroneal just distal to the anastomosis. The left femoral-popliteal was patent and the popliteal was narrowed distal to that anastomosis and the tibial-peroneal trunk was also narrowed. Flow into the right foot was routed through the peroneal bypass and collaterals into a reconstituted dorsalis pedis. In the left leg, the peroneal continued to the ankle with reconstitution of small dorsalis pedis and posterior tibial arteries. On December 11th, balloon angioplasties of the left distal popliteal and of the left tibio-peroneal trunk were performed. His right foot ulcers did not benefit from the procedures and the left foot broke down in the ensuing months. He was discharged home where a wound specialist provided outpatient care and Reganex was added to the program. Persisting pain and ulcers of both feet brought him to the Circulator Boot Clinic on January 20th, 1999. A nicotine-addict, he was still smoking and continued to smoke almost until his death.


Multiple areas of skin breakdown in the left foot attested to the severity of his ischemia. Lesions are seen here in the heel, arch and first toe.


Breakdown of the left 4th and 5th toes and of the plantar skin under the 5th metatarsal were also seen.


The right 4th and 5th toes likewise were breaking down.

The pulse volume curves of the midfoot were flat in both feet. Both legs were treated in the boot clinic usually three times a week over the next several months. The initial cultures of his toes grew out heavy growths of Pseudomonas aeruginosa and Corynebacterium species which were treated with oral ciprofloxacin and local gentamicin (injections prior to his boot treatments and in the Sea Soaks within the Miniboot). In August, a heavy growth of coagulase-negative Staphylococci was recovered from his left foot; Vancomycin and gentamicin were then injected into the infected and obviously necrotic areas of the toes.


On September 28th, the arch and heel of the left foot were healed. Granulations were forming over the necrotic area of the big toe.


September 28th, 1999: The left toes were cleaning up, but had many ulcers to heal. The right 4th and 5th toes were healed.

In January, he neglected to take his diuretics and was hospitalized for congestive failure for a few weeks in his University Hospital. In late January, he was again hospitalized and he died on February 3rd. Several months later, his son wrote the following letter of appreciation:

Comments: We could have done more for this man. Long-Booting might have helped his heart. More prolonged therapy might have cured his feet. His stopping smoking would certainly have helped. But, he was a sick man. Such people commonly remain at home for many months in pain with no hope. They may spend one to two percent of their life in misery. Here, we see another aspect of boot therapy: palliative therapy. We are told that 200 cases are enough to report. But we have had the privilege of taking care of so many more. A few follow before we end:


Case 200b: This 93 year old retired general had been hospitalized for a few weeks at a nearby hospital without relieving his pain or healing his ulcers. They healed nicely with outpatient boot therapy and remained healed until he died the next year.


Case 200c: At age 79, this lady had a history of myocardial infarction, congestive heart failure and an inability to heal the amputations of three gangrenous toes over several months at a nearby hospital.


With booting, the transmetatarsal amputation done in Bryn Mawr went on to heal.


Case 200d: This 79 year old man had type 2 diabetes, a previous smoking addiction and a history of myocardial infarction, organic brain syndrome, congestive heart failure, peripheral arteriosclerosis obliterans, venous stasis, lymphedema, and two months of painful leg and foot ulcers.


His legs improved with boot therapy and his pain was relieved. He was transferred to a nursing home where he died a few months later.


Case 200e: This 72 year old man had hypertension, hyperlipidemia and ten blue toes since his heart catheterization procedure in April 1999. He had coronary bypass surgery with the use of a saphenous vein in August 1999. His toe pain persisted and the skin began to break down.


When referred for boot therapy in September 1999, he had no distal pulses and the PPG waveforms in his feet were flat.


His pain was relieved and his foot lesions healed with Mini-Boot therapy.


Case 200f: This 85 year old man had type 2 diabetes, hypertension, atrial fibrillation and peripheral neuropathy. He was referred here after his vascular surgeon had drained and debrided a foot abscess.


He received antibiotics intravenously and locally with boot therapy during his two week hospitalization. The boot therapy was continued as an outpatient and he went on to heal.

 


He returned periodically for follow-up therapy of recurrent pressure sores under his first metatarsal-phalangeal joint. Here in 3/16/01 he returned for a follow-up examination in hopes of being dismissed from care. While his left foot appeared healed, examination of his right foot, his good foot, showed ischemic skin changes, callus, flaking and fungus-laden nails. Here we were assessing his blood flow. It is seen that the left foot, which had had boot therapy, now had the best blood flow. This course of events is common: treatment of the avascular foot over time restores blood flow and its mate becomes the bad foot. It makes sense to pump both feet in these patients if the insurance carriers will allow it.


Case 200g: This 45 year old type 1 diabetic presented with limiting claudication of his left leg.


His claudication abated and he was able to return fully to work.


Case 200h: This 57 year old diabetic had metastatic adrenal cortical carcinoma for which he received chemotherapy. Our assignment was to preserve his leg and relieve his pain.


His foot obviously improved but he died of his carcinoma and its complications.


Case 200i: This 44 year old man, diabetic for 23 years, presented with a 5 week history of an infected toe ulcer that had resisted the care of his family physician and podiatrist. He had no palpable pulses below the knee. The Doppler signals in his foot were low and monophasic. He could not feel the 5.07 monofilament and he had 12-inch two point discrimination. The exposed joint appeared infected and his x-rays eventually demonstrated osteomyelitis.


His culture showed heavy growths of Staphylococcus aureus and Corynebacterium and a light growth of Stenotrophomonas maltophilia. He was treated with oral Augmentin, local injections of vancomycin and the Mini-Boot.


Case 200j: Yes, we can treat lymphedema. Our pulsations with each heartbeat deliver much more energy than other lymphedema boots and leave the left soft and pliable.


Longstanding lymphedema associated with fibrosis as in this lady has only a partial result, however.


Case 200k: A 54 year old lady had quit smoking 2 months prior to presentation when she had 15 block leg claudication. She presented for boot therapy with two "trash feet" post coronary angioplasty and bypass surgery. A proximal dorsalis pedis was palpable in both feet. Her arm/ankle indices were 0.88 on the right and 1.03 on the left. The transcutaneous oxygen tensioon was 12 mm Hg on the dorsum of the right foot and 48 on the left. Minimal to flat PPG waveforms were found in the toes. Portions of the left 1st and 5th toes and all five right toes were gangrenous. She was treated local injections of gentamicin and vancomycin in to the gangrenous areas of the toes with pain and drainage. The injections were followed by Miniboot therapy with her feet immersed in Sea Soaks.


She had periodic debridements of loose eschar. The black eschar demarcated and separated in the left foot leaving intact skin and healed toes. The TcPO2 value in the right foot rose to 71 mmHg. The eschar also demarcated and began to separate but the foot, while improved, was not healed when she left our care.


Case 200y: Yes, it helps to have a few endocrinologists available in difficult cases. This lady had thyroid acropachy and her skin and feet were slowly restored to normal with thyroid replacement therapy. Unfortunately, follow-up photographs were not taken by the later housestaff who had not witnessed her feet on presentation. Such changes have been well known for years to the endocrine services (Nixon DW and Samols E: Acral changes associated with thyroid disease. JAMA 212:175, 1970).

Comments: We have to end somewhere. This case series documents that the Circulator Boot systems is successful in treating many patients thought to be untreatable or thought to require vascular reconstruction. Large areas of cellulitis can be cured. Osteomyelitis can be cured without amputations. A lack of palpable pulses does not mean surgical vascular reconstruction is necessary. We have not attempted to prove the following additional points but suspect it will be done. Long Boot therapy can improve congestive heart failure, can replace dialysis for many diabetics for one to two or more years, and may have a place in the handling of strokes and vascular lesions of the eye. Hopefully, some readers may be encouraged to investigate these points. Thank you for your attention.

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