Case 7: Necrotic Toes and Cholesterol Emboli Successfully Treated

Two Painful Feet on Presentation

This 70 year old insulin-dependent diabetic man noted progressive soreness of his toes a few days after cardiac catheterization.

He was referred three months later for boot therapy. He was found to have monophasic Doppler sounds in both anterior tibial arteries (signifying blockages in these arteries somewhere above the ankle test site), biphasic sounds and pseudohypertension in both of his posterior tibial arteries (signifying hard noncompressible arteries that were largely open above the ankle test site) and loss of the Doppler arterial sounds in all of his metatarsal arteries (signifying minimal to no arterial blood flow in the arteries in the distal third of the foot). The transcutaneous oxygen tension on the dorsum of both feet was "0". The distal third of each foot was ruboris on dependency. The distal 10% of the right 4th toe, 40% of the left 1st and 2nd toes and 20% of the left 3rd toes were black and mummifying. The distal halves of the right 1st and 2nd toes were purple and mottled on their plantar surfaces and very red on the dorsal surfaces. Bilateral amputation had been advised as a means to relieve him of his pain.

Cultures of the drainage at the margins of the necrotic areas were followed and he was given antibiotic injections through the black eschar on each of the badly compromised toes. His feet were pumped in Miniboots with his feet immersed in multi-electrolyte solution (Sea Soaks) containing appropriate antibiotics and urecholine.

Pain and anxiety were problems early in his treatments. His feet were extremely tender. Merely holding them was very difficult. The local injections were very trying but generally accompanied with a lessening of his pain after his boot treatments.

Over a few weeks of treatments 6 days/week, his pain abated. His feet slowly demarcated. The eschar was shaved back leaving a shallow rim of dry dead tissue. His distal Doppler sounds returned. He has become fully ambulatory. He has done well.

Improved Tissue Color and Integrity

And Demarcation of Dead Areas

Healed and Doing Well

Comments: Was there any other way to approach his problem? He already had a "bypass" to both ankles; his posterior tibial vessels were largely patent. He had no detectable vessels on the dorsum of his feet to accept a bypass to his dorsalis pedis arteries.... and if such could have been accomplished, runoff to the toes would likely have been poor to nonexistent.