Case 37: Visualization of Previously Absent Arteries on Post-Boot Arteriogram

The arteriogram of this 71 year old male diabetic ex-smoker showed a 50% stenosis of the deep femoral artery and multiple areas of narrowing in the superficial femoral down to the distal femur where the superficial femoral was totally occluded for a 10 cm segment. The right popliteal was visualized but diseased. The anterior tibial was totally occluded proximally and distally while its middle portion was visualized and diseased. Both the posterior tibial and the peroneal arteries were occluded in their proximal potions and were attenuated and diseased distally. His vascular surgeon saw no opportunity for bypass surgery and referred him for boot therapy. When first seen on June, 30, 1981, he complained of pain in his 3rd toe and heel on weight bearing and pain in his calf on walking a block. He was started on outpatient boot therapy. Initially no flow was detected by Doppler in his anterior tibial artery at the ankle; after a few weeks flow was detected and reached a maximum blood pressure of 98 mm Hg. (arm 164). In the posterior tibial an initial pressure of 48 mm Hg was found; it reached a peak of 78 mm Hg. In the peroneal artery, the initial pressure was 55; it peaked at 80 mm Hg. The initial pulse volume curve was 4 mm high and peaked at 8 mm. Seven follow-up studies were done during his nine weeks of therapy; the changes in the height of the Doppler wave-form and in blood pressure did not always move in the same direction at the three sites. Commonly the flow at two sites improved while it might decrease at the third site. The first photograph shows his foot on presentation; the right foot had a slight rubor in dependency. He seemed to be improving when his ischemic symptoms returned in greater severity. An arteriogram was performed and is compared with the original below. The second photograph shows his foot after the arteriogram; he has more dependent rubor and a small stage 2 ulcer on his big toe.

Presenting with Slight Rubor of the Right Foot

Sudden Increased Ischemia of Right Foot

The previously reported 50% obstruction in his deep femoral now appeared to be a significant stenosis in the origin of the superficial femoral artery. The rest of the arteriogram appeared to show a beneficial effect of his boot therapy: previously nonvisualized segments of diseased vessel were now seen. It was not clear why he had the sudden deterioration in his foot. Boot therapy effects little change in the vessels in the groin and high thigh. It is possible that the change in the origin of the superficial femoral explained his new ischemia. A Femoral-popliteal bypass was performed. Postoperatively, his vascular tests at the ankle were only marginally improved: Blood pressures 58 (anterior tibial), 78 (posterior tibial) and 83 (peroneal artery) and pulse volume at the ankle 10 mm. He continued with outpatient boot therapy and was able to gain relief of all of his pain.

Baseline Showing Few Vessels in the Low Thigh

Second Study Showing New Vessels in the Low Thigh

Baseline Showing Few Vessels in Mid-Calf

Second Study Showing Visualization of Peroneal and Anterior Tibial Arteries

Baseline Showing but a Few Arterial Twigs above the Ankle

Second Study Again Showing the Anterior Tibial and the Peroneal above the Ankle

Comments: While we have multiple noninvasive studies before and after boot therapy, we have few arteriograms. Those we do have were obtained in patients like this man who had an unsatisfactory initial result with his boot therapy. The arteriograms show increased collaterals and visualization of vessels not previously seen. Presumably, booting promoted the dissolution of clot in some vessels allowing their visualization.