The angiogram revealed iliac disease and 60 percent stenosis of the anterior tibial and posterior tibial artery of the left lower extremity. The vascular team decided to stent the lesion in the iliac artery and monitor the wound. Five days later, the wound still demonstrated no improvement. At this point, the vascular team decided to perform an angioplasty at the level of the anterior tibial artery and posterior tibial artery. Again, the team performed transcutaneous oximetry, which demonstrated an increase from 33 to 54 mmHg at the midfoot level. Arterial Doppler waveforms improved to a triphasic signal. The vascular surgery team said they had achieved optimal blood flow. The team continued appropriate local wound care with the patient on an outpatient basis. One month later, the patient was readmitted to the hospital for a non-healing wound with cellulitis. However, when the team employed hyperbaric oxygen therapy, they were able to heal the patient’s wound. This case demonstrates the fact that this patient had a minimal peripheral arterial occlusive disease. Even after the improvement of blood flow after interventional angioplasties, the patient still needed adjunctive therapy, specifically hyperbaric oxygen therapy, to achieve complete healing. It demonstrates that tissue hypoxia was the etiology in this problem wound, not diminished blood flow. Final Notes Dysfunction from autonomic neuropathy can be a complicating factor in the diabetic population. Identifying the patient with diabetic autonomic neuropathy will help clinicians assess the spectrum of the disease and subsequently place this patient in the “at risk” category, knowing that he or she could be at risk for ulcerations, gangrene or Charcot arthropathy. Dr. La Fontaine is an Assistant Professor in the Department of Orthopedics/Podiatry at the University of Texas Health Science Center. Dr. Brown is a first-year resident in the aforementioned department at the University of Texas Health Science Center. Dr. Steinberg (pictured) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.
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