Case 80: Both Legs Do Well in Patient with Diffuse Arteriosclerosis Obliterans

This 74 year old waiter was admitted to the Bryn Mawr Hospital with a non-healing ulcer over the medial malleolus of his right foot, secondary to a burn he suffered seven months previously. Two attempts at skin grafting had failed. Risk factors promoting his vascular disease had included obesity and smoking from age twelve to fifty. Pulse volume measurement at his ankles were reduced and pseudohypertension in the calves pointed to medial calcinosis of his tibial arteries. His arteriogam showed irregularities in his superficial and deep femoral arteries thought to be atherosclerotic plaque. The right popliteal artery had a 50% stenosis proximally, then a 2cm subtotal occlusion and finally a 5.5 cm stretch with a 50% narrowing. The left popliteal was markedly stenosed in its mid-portion and slightly narrowed distally. Both anterior tibial arteries were occluded. The distal portion of the right posterior tibial was occluded and the left posterior tibial was narrow and beaded throughout its course to the plantar artery. The plantar and dorsalis pedis arteries faintly visualized in the right foot. With such diffuse disease present, the radiologist did not recommend angioplasty and the vascular surgeon did not recommend bypass. His cardiologist referred him for boot therapy.

Two areas of beakdown on right leg...

And one on the left.

Long-Boot therapy was first begun on his right leg. Within a few weeks his vascular tests showed some improvements: a slight rise in his ankle pulse volume, a rise in the ankle pressure from 86 to 176+as measured by Doppler at the Dorsalis Pedis where the Doppler velocity curve also rose about 30%. In the posterior tibial, however, the Doppler velocity remained unchanged while his blood pressure dropped from over 200+(pseudohypertension) to a more realistic 170 m Hg. Therapy was then begun in his left leg where a previously undetected peroneal artery subsequently was found and the pulse volume likewise improved from 2mm to 6 mm.

Both legs healed and he became fully ambulatory.

His right ankle broke down again a few months later. His cardiologist referred him back for more booting, which was accomplished as an outpatient. He did well.

Referred back by his family doctor...

and healed again.

Comments: This man might have tried difficult distal bypasses on both legs. Both legs initially healed with boot therapy. His cardiologist was his prime advisor. When he relapsed, the cardiologist sent him back for more therapy and he did well. Some vascular surgeons and those physicians under their influence might have advised the patient that boot therapy obviously could not help him and that he must undergo a surgical procedure.... and if he did not fare well, he would not have fared well anyhow. Not so. .