Case 3: Failed Bypasses, Gangrene of Foot and Heart Failure

At age 65, this former smoker and insulin-dependent diabetic Saudi male presented at Bryn Mawr on May 21st, 1992 with a history of failed tibial bypasses to his right anterior and posterior tibial arteries. After the bypasses, his toe ulcers had extended leading to amputations of his right 1st, 2nd and 5th toes. Dry gangrene of the distal foot developed along with focal necrosis of the heel and lateral malleolus. Other problems included emaciation (BW 40Kg), a peptic ulcer, hepatitis C, a history of congestive heart failure, an estimated ejection fraction of 20% on MUGA scan and a small pressure sore under his left heel. Doppler waveforms were diminished and monophasic but detectable in all three tibial vessels at the right ankle. Pain sensation was diminished and 2-point discrimination increased to 5 cm on his left foot. He was treated with the long boot to support his heart and over time his ejection fraction improved to 44%. He received Miniboot treatments with his foot immersed in multi-electrolyte solution (Sea Soaks) containing both Urecholine and antibiotics to: Improve tibial blood flow Disseminate antibiotics which were injected into the obviously infected tissues Gently loosen and debride necrotic tissue Focal necrosis of his left first toe was also successfully treated.

Dorsal view of foot on presentation Lateral view of foot on presentation

Status of right foot on return to Saudi Arabia with Miniboot

Open ulcers on both feet on return May, 1997

Essentially healed right foot on June 28th, 1997

Comments: On arrival in 1992, the end of the foot of this man was dead and he had more proximal areas of necrosis on the side of his foot, lateral malleolus and heel. He had little distal blood flow and continued tissue necrosing was likely. He was advised no further vascular reconstructions were possible and that boot therapy was a slow process. Hence, he had the choice of immediate leg amputation with its risks or boot therapy over a year or more. It was explained that time was necessary for him to develop new blood flow under the dead areas, to develop good granulation tissue and to grow new skin. He chose boot therapy. He spent his initial two months in the hospital where he received 3-4 boot treatments daily. He became ambulatory and spent the next year receiving his daily treatments as an outpatient. His case another "kick to the moon"? He was failing under the care of others. We could offer no "standard" treatments to help him. With boot therapy, however, he regained the use of both legs, improved his heart function and, not emphasized above, dropped his BUN and creatinine levels 50%. To date, he has had the use of both legs for over 5 years.