Case 57: Family Request for Boot Overrides Surgeon's Decision and Leg Salvaged

At age 94, this nondiabetic lady was admitted to the hospital February 13th, 1989 for an arteriogram which revealed no possibility for an operation her vascular surgeon considered likely to succeed.

Her superficial femoral was occluded leaving her but modest collateral flow to the knee.

Her tibial vessels were seen proximally but were occluded in the lower calf.

A portion of the anterior tibial was seen above the ankle but had poor runoff into the foot.

A subsequent Urokinase infusion failed to improve the blood flow into her foot. She was discharged for "observation". March 3rd, 1989 she was readmitted for a leg amputation. She had rest pain and could not walk.

The tip of her 4th toe had become gangrenous and she had painful splits of focal necrosis beneath her 5th toe and on her heel

The dorsum of her foot was reddened with likely cellulitis and the tip of her 3rd toe appeared to be breaking down.

A friend on the medical service suggested she might benefit from boot therapy. Her surgeon advised that it was not appropriate in her case. Her cardiology consultant asked for a boot consultation, nonetheless. Boot therapy was begun March 8th. She tolerated the therapy well predominantly receiving full leg booting with an extended Mini-Boot in a chair. By March 19th her pain was essentially gone and she was walking in the hall. She was discharged march 20th to be booted in the office.

She was subsequently hospitalized for chest pain for three days in April by her cardiologist. In May, she was hospitalized for a duodenal ulcer with gastric outlet obstruction, arteriosclerotic heart disease and congestive failure. During these and other hospitalizations occasioned by her heart disease, she received boot therapy. During the intervals between her hospitalizations, she received boot therapy if she became aware of leg pain. She was readmitted to the hospital in June of 1990 again by he cardiologist. She had become depressed and refused nourishment. Suffering from the "dwindles", she died July 8th, 1990. Her leg held up until her death. She and her family were grateful that she could walk until her last hospitalization and maintain her independence around her house.

A small scab persists at the site of autoamputation of the end of the 4th toe.

Comments: The vascular surgeon here rarely thought boot therapy was indicated. Indeed, a case like this is not easily cured by boot therapy. The lady could not tolerate the usual form of long boot therapy which entailed keeping her leg horizontal. Gravity may be important in such legs in helping to prime the leg with blood. We do not want to pump "an empty leg". The effect of gravity may be increased by pumping the leg in a high reverse Trendelenburg position (bed tilted at 6-8 degrees with the head up). Or the patient may be pumped while sitting in a chair using an elongated Mini-Boot bag that reaches the groin. Again, infection must be sought and vigorously handled in patients like this. Here, for example, the necrotic portion of her toe was infiltrated with gentamicin to reduce the seeding of bacteria from her toe to the foot.