Case 68: Salvage of Legs in Diabetic COPD Patient with Both Diffuse Arteriosclerosis Obliterans and Showers of Emboli after Surgery on Aortic Aneurysm

At age 85, this diabetic male with chronic obstructive pulmonary disease was admitted on March 12th, 1991 to the Bryn Mawr Hospital for resection of an abdominal aneurysm. His leg arteriograms showed diffuse disease with stenotic areas in both superficial femorals and popliteals and a single tibial runoff that faded distally. Peri-operative showers of emboli left the distal portions of both feet purple and promoted the development of bilateral heel ulcers. Postoperative heparin helped little. March 24th, 1991, he was referred for boot therapy.

Abdominal Aneurysm His Likely Source of mboli

Irregular Superficial Femoral Arteries with Focal Stenoses

Irregular Popliteal Arteries with Focal Stenoses

One Vessel Runoff in Lower Half of Calves

Painful Feet on Presentation for Boot Therapy: Note that all ten toes are purple in spite of elevation and that the feet are likewise ruborous to a line almost at the ankle. The physician clinical chart notes are also shown. March 24th, 1991.

Plantar view March 24th, 1991. The deep purple areas of his toes went on to mummify and, with a little help, autoamputate.

After a few months of therapy, normal skin color was restored to most of his feet. The distal portions of most toes had autoamputated and healed. He was ambulatory with the aid of an air cast for his right leg.

He refused to consider resection of his right toe and first metatarsal. The margins of the dead bone were scraped in the office to allow skin to cover either a clean surface or marrow. The skin slowly closed over the gap.

His usual treatments included a cleansing foot soak in Sea Soaks and dilute peroxide, Mini-Boot treatments with his feet immersed in Sea Soaks containing appropriate antibiotics and periodic cultures. Any foci of infection were injected locally with appropriate antibiotic before the boot treatment. He required no more hospitalizations for his feet. He was hospitalized several times, however, by his allergist for asthma and COPD. He died May 7th, 1994 due to his lung problems.

Comments: This man survived his leg problems 38 months and was ambulatory except when his pulmonary problems were severe. He avoided bilateral amputations and maintained an independence for which his elderly wife was grateful. His course could have been shortened with earlier referral for boot therapy and later amputation of his right first ray. He demonstrated that exposed bone can be covered even in an elderly diabetic with severe peripheral ischemic disease. Can't you hear your surgeon saying that he just had to have more surgery? No so!