Exploring Limb Salvage Options In Patients With Chronic Limb Ischemia

By John E. Aruny, MD, Peter Blume, DPM, Bauer Sumpio, MD, PhD, and Benjamin Buren, DPM

Case Study: A Patient With PVD And Chronic Limb Ischemia

   The patient is a 72-year-old woman who was transferred from a local hospital for continued workup of her peripheral vascular disease (PVD) and ischemia of the third digit on the left foot. The patient had undergone an attempted left lower extremity bypass. However, the surgeons found the autogenous veins were unsuitable to serve as a conduit and the procedure was aborted. She was admitted to Yale-New Haven Hospital under the podiatric surgical service for a final attempt at limb salvage.    The patient had a significant past medical history including PVD, diabetes, coronary artery disease, hypertension, hypercholesterolemia, myocardial infarction, chronic renal insufficiency, peripheral neuropathy and gangrene of the left third toe. She underwent a coronary artery bypass and cholecystectomy on Sept. 7. An attempted lower extremity bypass graft was unsuccessful on Sept. 24.    Her medications included oxycodone hydrochloride 40 mg bid, atorvastatin calcium 10 mg daily, metoprolol 50 mg bid, amlodipine 5 mg daily, lisinopril 20 mg daily, stool softener 100 mg daily, aspirin 81 mg daily, a daily multivitamin and silver sulfadiazine cream. The patient is allergic to ibuprofen.    In general, the patient was in no apparent distress and was alert and oriented. She had a regular heart rate and rhythm with positive S1 and S2 heart sounds. Her lungs were clear to auscultation bilaterally with no rhonchi, rales or wheezing. Her abdomen was soft, nontender and nondistended with positive bowel sounds.    The lower extremity examination revealed a left, dry necrotic third digit with no discharge and no erythema. The patient had been using silver sulfadizaine cream on the dorsal and plantar aspects of the foot. The patient had nonpalpable dorsalis pedis and posterior tibial pulses with weak monophasic Doppler signals. Multiple ischemic lesions on the dorsal and plantar aspect of the forefoot were secondary to recent skin biopsies. The patient also had skin staples to the dorsum of the ankle and lower leg from the recent lower extremity bypass attempt.

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