Case27: Holding the Line in Patient with Severe Iliac Disease

This 71 year male presented with many of the complications of a long cigarette addiction: pulmonary emphysema, generalized arteriosclerosis with a past history of two myocardial infarctions, a tortuous dilated and calcified aorta, a right renal artery occlusion, half block claudication of the right leg, and some stage 2 ulcers of some right toes that he attributed to his podiatrist. He now had been too sick to smoke for two months. His pulse volume study showed flat tracings in his right leg. His accompanying arteriograms showed only collateral flow into his right leg and few vessels visible in his thigh. His left superficial femoral was occluded but there were numerous collaterals in the left thigh (photographs).

Nonvisualization of Right Iliac and Femoral Vessels

Numerous Collaterals Only in Left Thigh

He received six Long-Boot treatments as an outpatient and obtained symptomatic relief of his claudication. Nine months later, he presented again but on this occasion with purple painful toes of his left foot. He was given two weeks of Long-Boot treatments in the hospital and transferred to a nursing home. His legs were intact but his prognosis was guarded due to his generalized debility, anorexia and uremia. He and his family attributed his capacity to walk the nine months prior to this last hospitalization to his boot therapy.

Comments: This man was too debilitated to consider any vascular reconstruction procedure that might have been offered. He represents a class of patients that generally do poorly with boot therapy: those with advanced iliac disease and little to no inflow into the afflicted leg. Children, of course, have considerably lower blood pressures than adults. They may perfuse a leg very well with a thigh blood pressure of 60 to 80 mm Hg. Patients like this man tend to have high blood pressures in the brachial arteries and may present with thigh pressures in the 40-80 range (if the leg is viable) and lower when the leg is obviously deteriorating. Boot therapy is unlikely to affect obstructive disease above the groin. It may, however, open the leg itself and create a low pressure perfusion system. The latter may suffice especially if the patient is mentally clear and vigorous enough to use his leg for some form of regular activity. Inactivity and stasis are problems. Such activities like riding a stationary bicycle are to be encouraged. Boot therapy in these patients should probably not be instituted if there is mottling and pain of the whole leg and if there is no detectable flow by Doppler anywhere in the leg. This is especially true if the vascular surgeon has determined that no reconstruction will be attempted regardless of any success boot therapy has in opening up distal vessels. It is very frustrating for the boot service to restore color to a mottled leg over the weekend only to learn that the surgeon was planning a leg amputation at his/her next operating day on Tuesday..