Case 5: Rubor Mortis and Restoration of Blood Flow to Dead Tissue

Twenty-five Legs with Cholesterol Emboli and Trash Feet

Cyanosis and Early Demarcation of Dead Distal Foot

Cold pulseless leg after her arteriogram (the needle was introduced into a atherosclerotic plaque resulting in distal emboli).

Subsequent operative procedures: bilateral lumbar sympathectomy, femoropopliteal bypass, tibial end-embolectomy and a patch graft angioplasty.

Referral for boot therapy with a cold foot that was cyanotic in its distal 3rd.

Doppler tests improved with her boot therapy: the height of the waveform rose from 23 to 31 in the anterior tibial at the ankle, from 0 to 15 in the dorsalis pedis, from 0 to 24 in the posterior tibial at the ankle and from 24 to 44 in the peroneal at the ankle; the respective measured blood pressures rose from zero to 145 (AT), 175(PT) and 170 (Per) mm Hg.

After each boot therapy, the skin over the 1st and 2nd metatarsal heads and on the 1st and 2nd toes became a crimson red and remained red for up to 90 minutes.

Her surgeon performed a beneath-the-knee amputation.

The tissues of her foot were examined microscopically.

Rubor Mortis of 1st and 2nd Toes and Blanching of Toes 3-5	Capillary Flow through Damaged Capillaries and Dead Tissue

Comments: Rubor Mortis is relatively common in the end-stage feet referred for boot therapy. Blood flow is restored into damaged tissue which cannot utilize the oxygen thus leaving the blood, which may not move in the absence of boot pulsations, red. Proximal living tissue, on the other hand may slowly return to a pre-treatment cyanosis. If the rubor mortis is not too extensive, we are salvaging some of these feet today. We support the damaged tissue by keeping it hydrated with multielectrolyte solution (Sea Soaks-TM), reducing the skin bacteria by adding gentamicin to the soak solution and using topical oxygen to keep the skin envelope intact (the outside few mm of skin does breathe). The latter measures allow additional days for boot therapy to restore adequate blood flow to heal the foot. Restoration of blood flow to the dead tissue of this lady was more of a stunt than a service. It was a "kick to the moon" in that other techniques cannot do it. Such disaster following arteriograms and angioplasty is very disconcerting for the physician. They may respond with denial hoping the foot will get better spontaneously and believing that little can be done. Or as in this case they may respond with a flurry or surgical activity. In our experience, the latter may be counterproductive (See the Angiology article on 2177 cases). Earlier referral for boot therapy might have helped. Below are the results of treatment with the Circulator Boot in the cases in our computer listed found listed under emboli.

Fifteen Patients and 25 Legs at Risk of Amputation Due to Emboli - Trash Feet

Below are given the patient initials with right or left leg designated, their age, their sex, the Wagner classification of their foot ( for description of Wagner classification), their New York Heart classification, their type of diabetes, their smoking history, the type or number of previous vascular surgical procedures they underwent, and their response to boot therapy. All were at risk of leg amputation. Several are reported in more detail in these case histories (Cases 7, 16, 68, 163, 189 and the 5th, 10th and last patients in 200).

Initials & Leg	Age	Sex	Wagner	NY Heart	Walking	Diabetes	Smoking	Prev VP	Result
RN RL	72	M	4	4	150ft	0	former	Aortic aneurysm repair	Improved
RN LL	72	M	4	4	150ft	0	former	Aortic aneurysm repair	Improved
FA RL	68	F	0	2	150ft	0	-	Coronary Angioplasty	Healed
OL RL	68	M	2	2	150ft	0	former	Fem-pop, renal artery angioplasty	Healed
OL LL	68	M	2	2	150ft	0	former	renal artery angioplasty	Healed
CL RL	58	M	4	2	0	2	0	aorto-iliac bypass	Healed
CL LL	58	M	4	2	0	2	0	aorto-iliac bypass	Healed
W RL	62	M	4	2	?	0	former	0	Healed
HJ RL	46	M	5	3	0	1	0	Streptokinase	Healed
WR RL	84	M	5	3	0	2	former	Aortic aneurysm resection	Healed
WR LL	84	M	5	3	0	2	former	Aortic aneurysm resection	Healed
RM RL	72	F	5	2	0	0	former	Coronary Angioplasty	Healed
BR RL	70	M	4	3	0	2	former	heart catheterization	Healed
BR LL	70	M	4	3	0	2	former	heart catheterization	Healed
MJ RL	69	M	5	3	0	2	former	Coronary artery bypass graft	Healed
MJ LL	69	M	5	3	0	2	former	Coronary artery bypass graft	Healed
DF RL	72	M	4	3	0	0	former	heart catheterization	Healed
DF LL	72	M	4	3	0	0	former	heart catheterization	Healed
RC RL	70	M	4	4	0	2	active	arteriography and hemodialysis	Improving, dies a month later
RC LL	70	M	4	4	0	2	active	arteriography and hemodialysis	Improving, dies a month later
RF RL	67	F	5	2	0	0	former	arteriography	BKA
EB RL	54	F	4	3	0	0	former	coronary angioplsty and bypass	Improved, leaves treatment before healed
EB LL	54	F	4	3	0	0	former	coronary angioplasty and bypass	healed
TC RL	84	F	4	3	0	0	0	arteriogram & iliac shunt	pain free & healed
TC LL	84	F	4	3	0	0	0	arteriogram & iliac shunt	pain free & healed