Case 69: Total Relief of Rest Pain with Boot Therapy after Unsuccessful Therapy with Urokinase

This 79 year old man had stopped smoking eight years prior to his admission to the Bryn Mawr Hospital in August 1987. He had not been aware of leg claudication possibly because of exertional dypsnea limiting his walking capacity. Six days prior to admission he developed claudication of his left leg and subsequently rest pain. On admission he had no palpable pulses distal to his femoral in his left leg. An arteriogram revealed heavy plague in the iliac arteries and the findings below:

His right superficial artery was dilated and irregular. The left superficial femoral was occluded high up in the groin but faint calcifications in the vessel wall outlined the course of the vessel through the thigh. A smaller left deep femoral was seen and noted to have poor collateralization to and around the knee.

The popliteal was occluded and distally only a trace of a tibial vessel was seen.

Therapy with Urokinase was attempted with no lysis noted by the radiologist. Slight discoloration of his left thigh developed perhaps due to extravasation of blood. His rest pain persisted and he was bedridden. On the fifth hospital day, he was referred for boot therapy. He was given Long-Boot treatments with a sleeve from his groin to his ankle only to the left leg while in the hospital and then to both legs as an outpatient. His pain gradually disappeared and, when he could walk the length of the hall, he was discharged to outpatient therapy. His walking distance continued to improve leading him to exclaim that "I am walking better than I have in forty years." He was discharged and commenced traveling and an active life only to die suddenly December 18th, 1987 presumably from an acute myocardial infarction.

Comments: It is possible that his Urokinase therapy did have some benefit and made his subsequent boot therapy more effective, but no effect of the Urokinase was documented. We have combined systemic Urokinase therapy and booting in an occasional patient and found it quite effective. As the Urokinase requires multiple blood tests and a bed in our Intensive Care Unit in our hospital, we have generally avoided its use. This man might have been successfully treated early without hospitalization if he had been referred at the onset of his claudication. Patients with diffuse arteriosclerosis like this man, of course, have a reduced life expectancy. We have had no patients die while in the boot and few die within a few days of being booted. Improving leg function and exercise tolerance in arteriosclerotic patients, however, may potentially add a new burden on the heart. Given the approval of the referring physician and the insurance industry, we recommend putting an Omni Heart Monitor on all of these patients, as a "poor man's stress test", to rule out the presence of significant ischemic heart disease. At present we are booting many of these patients in our "cardiac-assist mode" (both legs, groin to toes, one leg compression after each heartbeat) and following the effect on the Omni Monitor. We have sent an occasional patient off for coronary bypass.