Case 28: Rechannelization and New Collaterals then Distal Bypass

It hurt this man to come to the Bryn Mawr Hospital for care; he was devoted to another nearby community hospital. He had had know diabetes mellitus for fifteen years and hypertension for forty years. In May 1982, he underwent a left carotid endarterectomy and a Gruntzig balloon dilatation of his right iliac artery at his favorite hospital. His arteriogram showed a total block of his superficial femoral with stenoses in his deep femoral and multiple stenoses and occlusions in his tibial vessels which did not visualize distally. He was considered inoperable and referred for boot therapy which initially was performed as an outpatient. He improved clinically and reluctantly agreed to enter Bryn Mawr Hospital June 23rd for a more intensive boot program.

Presenting with Strawberry Toes Painful at Rest

Positive physical findings on admission included : a systolic ejection murmur along the left sternal border to the apex, absent pulses below his femorals, bilateral ankle edema, reddish discoloration with fine strawberry red spots of his right foot, and numerous dark spots and a shallow ulcer under his metatarsal heads. His EKG showed a probable anterior myocardial infarction of undetermined age. He was given Long-Boot treatments three to four times a day for two unhappy weeks; he did not like our hospital, his room, his nurses or his food. He definitely was not a Bryn Mawr man. His rest pain disappeared and his sleep improved. Walking continued to be difficult due to pain on the sole of his foot at his ulcer site (not shown). He sought discharge and agreed to have a follow-up arteriogram on July 14th in hopes that his boot therapy had opened a distal vessel which could be bypassed at his hospital. The arteriogram showed a slight decrease in the length of the blocked segment of the superficial femoral artery, an open popliteal and an anterior tibial that was blocked in its upper third but could be traced from the knee into the foot

Baseline (Left) and Follow-up (Right) Films Lined Up Showing Extension of SFA and New Collaterals

Open Popliteal Segment at Baseline (Left) and Follow-up (Right) with More Collaterals below the Knee (Right)

Open Anterior Tibial from Mid-Leg into Foot on Follow-up

Foot on Transfer for Bypass

His foot color was thought to be improved on discharge. The photograph shows a small abrasion he incurred secondary to trauma. On July 19th, he underwent a right femoral- tibial bypass procedure with his saphenous vein. Postoperatively, he lost his pulse and had to return to the operating room for a graft revision. Subsequently, the graft did well and his pulse remained strong until his death five days later. Unfortunately, he experienced a perioperative myocardial infarction leading to need for ever increasing cardiorespiratory support and his eventual death on July 24th.

Comments: We actually have few post-boot arteriograms (but 100's of Doppler studies). Those we do have were obtained in patients who for one reason or another could not undergo prolonged treatment programs. These films illustrate a problem with serial arteriograms: it is hard to obtain the same views with the same exposures from study to study, especially if different institutions are involved. We would have continued to boot this man had he remained with us. After his bypass procedure, we might have booted his other leg for vascular support given the opportunity. Fixed chronic lesions are only slowly affected by boot therapy; it is hard to turn around the effects of lifetime habits within a few weeks. Patients with severe heart disease may appear quite fit while they are receiving boot treatments. The Circulator Boot is a supportive device. Here the physicians mistook his apparent good health for evidence he could undergo bypass surgery..