Case 52: Leg Saved in Patient with Buerger's Disease and History of Two Unsuccessful Bypasses

This 48 year old man (born January 12th, 1945) presented with a 30-year history of smoking, moderate obesity (relative weight 1.28) and a history of intermittent phlebitis over the previous 20 years. His 1992 femoral-popliteal bypass became occluded in early 1993 leading to unsuccessful therapy with streptokinase and urokinase. A painful ulcer developed on his big toe. He sought out a surgeon willing to bypass his leg again and was referred to Bryn Mawr. On February 5th, 1993 a right femoral-posterior tibial bypass was accomplished with a vein taken from his left leg. Runoff was poor and the graft failed in a few days. On February 9th a boot consultation was requested.

His transcutaneous PO2 (TcPO2) was zero and his transcutaneous PCO2 (TcPCO2) was over 100 mm Hg on the dorsum of the foot pointing to severe ischemia. Doppler sounds were absent below the lower calf. The lower leg incision was discolored and subsequently broke down leaving an ulcer from the upper calf to the lateral malleolus.

Foot and Leg on Presentation for Boot

Cyanotic Foot and Painful Big Toe Lesion

He was transferred to the boot service. The discolored skin of the foot was washed daily in Sea Soaks and gentamicin to maintain hydration and decrease the skin bacteria count. Topical oxygen therapy was continued after the wash throughout each 24-hour period (a single layer of gauze was placed over the skin to keep the O2 bag from sticking to the skin; an O2 catheter was placed over the mid-foot; a disposable plastic bag was placed over the lower third of the leg; a layer of gauze was wrapped over the bag and around the leg to contour the plastic bag against the skin forcing the O2 flowing at one liter a minute against the skin). Mini-Boot and Long-Boot treatments were performed over the O2 bag 3-4 times a day. Regular cultures were obtained and appropriate antibiotics were given both orally and in his Sea Soaks. Anti-fungal therapy likewise proved helpful (Fluconazole orally and Amphotericin-B in his Sea Soaks). He was discharged with both Long- and Mini-Boots at home where he continued his hospital program, including the topical O2 therapy. Doppler sounds slowly reappeared at his ankle and in his foot. His TcPCO2 fell more quickly than his TcPO2 rose. He returned to work ambulating in a plastic walking case in July 1993. His toe ulcer healed as did a newly discovered subungual abscess in July. His leg incision was not fully healed until August 1993. He has developed diabetes and is well controlled on diet and oral agents. His hypertension is treated with Accupril. He booted his leg twice daily through most of 1993 and less frequently in 1994. In 1996 he continued to boot his leg a few times a week. He is fully ambulatory and working an eight hour day.

Leg Incision and Subungual Abscess Healing

Lesions Almost Healed and Possible Drug Rash over Leg Incision

Comments: This man had the advantages of youth and mechanical intelligence in enabling him to undertake a home boot program. His initial vascular testing suggested his skin was in imminent danger of breaking down, Indeed, his suture line did breakdown. Sea Soaks washes and topical O2 were used to maintain the skin envelope allowing time for the boot to slowly return blood flow to the foot. He stopped smoking and his previous and new risk factors were properly addressed. He has done well.