Treatment of end-stage "Trash feet" with the end-diastolic pneumatic boot
ABSTRACT This study reassessed the clinical effect of Circulator Boot (CB) therapy in patients with cholesterol embolization syndrome (CES) of the lower extremities. The medical records were reviewed of 27 patients consecutively referred to the Bryn Mawr Wound Care and Vascular Center with CES who had not responded to previous therapies. All patients with CES referred from January 1, 1997, to September 19, 2005, were followed up and included in the study. The alternate therapy offered for most patients at the time of referral was limb amputation. The median age of the patients was 65 years (age range, 46-84 years) at the time of diagnosis. Healing of CES was observed after a median interval of 11 months (range, 3-32 months) following the initiation of CB therapy. The total number of legs treated was 41. Of 41 legs, 33 (81%) were totally healed, 6 (15%) improved, and 2 (5%) were amputated. After an initial period of improvement, one patient died a month later of causes unrelated to CES or CB therapy. Another patient improved and discontinued treatment before he was totally healed. Cholesterol embolization syndrome is seen predominantly in patients following cardiac or vascular procedures but may occur spontaneously. The CB seems to be the only effective noninvasive therapy for CES. Early initiation of therapy is essential to minimize tissue loss and patient discomfort.
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ABSTRACT: To determine the clinical effectiveness of the end-diastolic pneumatic compression boot and of local antibiotics in treating limb lesions associated with diabetes and peripheral arterial, venous, and neuropathic disease. Office and hospital data were kept over 15 years on 2177 episodes of leg problems classified by the Wagner method for 1514 legs of 1035 patients largely referred because of failure of standard therapies. The fate of the untreated legs served as a controls when possible. Healing or improvement of treated legs was seen above that in the literature in all Wagner categories and was significant (P < 0.001) compared to the "control" leg, which deteriorated in 38.7% of patients. Significant risk factors against a successful outcome included smoking, inability to walk, increased home distance from the boot center, loss to treatment, hemodialysis, a Wagner 4-5 classification, inoperable iliac occlusions, vascular procedures before or after referral for boot therapy, and an aggressive vascular surgeon. Neuropathy allowed successful treatment of lesions nondiabetic patients could not tolerate. Relapse was significantly more frequent in arteriosclerosis obliterans (ASO) patients with diabetes than without diabetes and in patients with neuropathy than in those with ASO. Diabetes did not affect the relapse rate in stasis disease. The overall percentage of legs having major amputations was low: 2.5% for diabetic legs at the initial treatment episode, 1.6% at the time of a relapse, and 4.1% after seeking treatment elsewhere. For nondiabetic patients, the respective risks were similar: 2.0%, 1.2%, and 2.9%.Angiology 05/1997; 48(5 Pt 2):S17-34. DOI:10.1177/000331979704800503 · 2.37 Impact Factor
Annals of the New York Academy of Sciences 04/1997; 811(1). DOI:10.1111/j.1749-6632.1997.tb51983.x · 4.31 Impact Factor
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ABSTRACT: Objectives. We sought to determine the influence of plaque morphology and warfarin anticoagulation on the risk of recurrent emboli in patients with mobile aortic atheroma.Background. An epidemiologic link between aortic atheroma and systemic emboli has been described both in pathologic and transesophageal studies. Likewise, a few studies have found an increased incidence of recurrent emboli in these patients. The therapeutic implications of these findings has not been studied.Methods. Thirty-one patients presenting with a systemic embolic event and found to have mobile aortic atheroma were studied. The height, width and area of both immobile and mobile portions of atheroma were quantitated. The dimensions of the mobile component was used to define three groups: small, intermediate and large mobile atheroma. The patients were followed up by means of telephone interview and clinical records, with emphasis on anticoagulant use and recurrent embolic or vascular events.Results. Patients not receiving warfarin had a higher incidence of vascular events (45% vs. 5%, p = 0.006). Stroke occurred in 27% of these patients and in none of those treated with warfarin. The annual incidence of stroke in patients not taking warfarin was 0.32. Myocardial infarction occurred in 18% of patients also in this group. Taken together, the risk of myocardial infarction or stroke was significantly increased in this group (p = 0.001). Forty-seven percent of patients with small, mobile atheroma did not receive warfarin. Recurrent stroke occurred in 38% of these patients, representing an annual incidence of 0.61. There were no strokes in patients with small, mobile atheroma treated with warfarin (p = 0.04). Likewise, none of the patients with intermediate or large mobile atheroma had a stroke during follow-up. Only three of these patients had not been taking warfarin.Conclusions. Patients presenting with systemic emboli and found to have mobile aortic atheroma on transesophageal echocardiography have a high incidence of recurrent vascular events. Warfarin is efficacious in preventing stroke in this population. The dimension of the mobile component of atheroma should not be used to determine the need for anticoagulation.Journal of the American College of Cardiology 02/1998; 31(1-31):134-138. DOI:10.1016/S0735-1097(97)00449-X · 15.34 Impact Factor