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Attempting Limb Salvage In A Patient With Critical Limb Ischemia And Multiple Comorbidities

Are there other options to consider when multiple providers have advised below-the-knee amputation for a patient? With an intriguing case study, this author illustrates how a concerted, multidisciplinary approach can still result in limb salvage despite complications and issues with patient non-adherence. 

A 64-year-old Caucasian male with a history of critical limb ischemia first presented in April 2017. He had a past medical history of coronary artery disease, hypertension, chronic obstructive pulmonary disease (COPD), kidney disease and daily tobacco use. The patient had a myocardial infarction in 2009 and in 2015, he was diagnosed with an abdominal aortic aneurysm (AAA). 

A few months prior to presenting to my office, the patient suffered an aortic dissection, which led to critical limb ischemia. Within one month of the repair of the aortic dissection, the patient had a carotid bypass. Shortly thereafter, he suffered complications from a previous renal stenting, which resulted in renal failure and initiation of hemodialysis. 

Approximately one month after the aortic dissection and while the patient was still hospitalized, he had a thrombotic storm event and noticed signs of ischemic lesions and dermatologic manifestations of thrombosis, along with discoloration to the digits of the left foot. Over a period of three weeks, he gradually developed cyanosis and subsequent gangrene to the distal aspect of the involved foot. The patient consulted four doctors who all recommended a below the knee amputation (BKA) of the left leg. I accepted a referral to provide an additional opinion for this patient. 

The patient had an ejection fraction of 40 percent and was still on hemodialysis. Upon examination, it was apparent the patient had diminished pedal pulses. There was dry gangrene on the left foot with a line of demarcation from dorsal to plantar (see top photo above). The gangrene extended more proximally plantarly than dorsally and circumferentially from the midfoot to the digits with necrosis and desiccation. At the line of demarcation, there was a fibrous subcutaneous wound base with proximal transition to normal skin. 

Cultures revealed Finegoldia magna (an anaerobe) and Staphylococcus aureus, leading to initiation of doxycycline and metronidazole. Debridement of the subcutaneous tissue revealed underlying bleeding tissue, which indicated some level of healing potential. The vascular surgeon indicated the patient had maximal vascularization with optimal pedal pulses and adequate perfusion to the left ankle. He also felt there was sufficient blood flow to the midfoot to possibly heal a transmetatarsal amputation (TMA). I advised the patient as to the importance of smoking cessation and the option of hyperbaric oxygen therapy (HBOT). After evaluating his case, I felt the differential surgical options included a proximal TMA versus a Chopart amputation versus a BKA. 

Planning A Multidisciplinary And Staged Approach To Limb Salvage

In the first phase of the surgical plan, we debrided the demarcation site between the gangrene and the healthy tissue, and applied a skin graft substitute. The goals of this initial approach were to allow for more skin healing and prepare an adequate flap for a TMA. The patient began HBOT. Two weeks after this first surgery, the patient developed acute pancreatitis, resulting in a one-week hospitalization and discontinuation of HBOT. During hospitalization, there was consultation regarding proper nutrition for wound healing. The area of graft application showed new tissue growth and wound progression. 

One month after the first procedure, I performed a proximal TMA at the level of the metatarsal bases. I utilized a dorsal to plantar flap instead of plantar to dorsal due to the proximal level of the plantar foot gangrene but there was a persistent tissue deficit at the distal stump. In order to complete this coverage, I applied a split-thickness skin graft, which was harvested from the patient’s left thigh.

The patient did not adhere to non-weightbearing instructions postoperatively. The split-thickness skin graft failed and I advised resuming HBOT for a failed flap. He continued to smoke and was not consistent in keeping his postoperative HBOT appointments. During this period, he suffered from nausea and episodes of vomiting due to acute pancreatitis along with sensitivity and pain to the surgical site. The donor site on the left thigh healed within two weeks. He received local wound care at the distal graft recipient site. I removed the sutures at three weeks and the patient subsequently began partial weightbearing (heel touch only) a week later in a pneumatic walking boot with a walker.

At five weeks post-op, the patient had minimal pain, the incision closed and the patient continued to ambulate in his walking boot with walker assistance. At nine weeks, the patient was completely healed. At 12 weeks, he progressed to custom-made shoes with toe fillers and full weightbearing. One month later, he demonstrated adequate gear switching on his motorcycle. Six months after his initial surgery, he returned to his usual full activity baseline. 

Final Thoughts

This is an extreme case of limb salvage and long-term wound care. The successful outcome of this case resulted from a multispecialty approach including vascular, cardiology, infectious disease, internal medicine, nephrology and podiatry. In addition, innovation on the usual TMA flap construction, adjunctive HBOT and aggressive attention to complications at an early stage all contributed to the result in this complex case. 

Dr. Balkaran is a diplomate of the American Board of Foot and Ankle Surgery, a Certified Wound Specialist and was a Division President of the American College of Foot and Ankle Surgeons. She is in private practice in Mount Dora, Fla.

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By Joanne Balkaran, DPM, CWS, FACFAS
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