An 80-year-old female patient was admitted for severe pain in the left foot. She had injured the sole of the left toes a few days before admission, and the area had become ulcerated. She had a history of diabetes, coronary artery disease, and renal disfunction that did not require dialysis; however, all of her diseases were being controlled with medication. On admission, the left foot was swollen red, and the first toe was gangrenous (Fig. 1). She had a fever of 39 °C with respiratory distress, and her level of consciousness was “delirium.”
A laboratory examination showed that the white blood cell (WBC) count and C-reactive protein (CRP) level were increased at 21900/μl and 28.51 mg/dl, respectively. The left lower limb pulse was not palpable, the ankle-brachial index (ABI) was 0.36, and the skin perfusion pressure (SPP) of the foot was 14 mmHg. A duplex scan showed no flow in the left external iliac artery (EIA) and a poor flow below the left femoral artery. We clinically diagnosed her with severely ischemic limbs with sepsis due to foot gangrene.
Broad-spectrum antibiotics of meropenem and vancomycin were immediately administered, and the necrotic first toe was amputated under local anesthesia with pus discharged on the day after admission; methicillin-resistant Staphylococcus aureus was detected in culture of the pus. Subsequent angiography of the left lower limb revealed the presence of an occlusive lesion of the EIA and below the distal superficial femoral artery (SFA); however, the dorsal artery was enhanced via the collateral circulation. Endovascular angioplasty of the EIA was performed with a bare metal stent (SMART Control 8.0 mm × 100 mm; Cordis, Miami Lakes, FL, USA). The gangrenous area had gradually been confined to the toes. Three days later, metatarsal amputation was performed under sciatic nerve block anesthesia (Fig. 2a). At 10 days after admission, the fever decreased to 36 °C, and her level of consciousness recovered to a clear state. The WBC count and CRP level decreased to 13800/μl and 11.85 mg/dl, respectively.
Left femoro-dorsal artery bypass was performed under general anesthesia using the ipsilateral great saphenous vein in a reversed fashion 14 days after admission. However, ultrasonography to make a preoperative evaluation revealed that the left great saphenous vein was complicated with varicose veins (dilatated generally to about 6 mm or 8 mm in diameter, with some aneurysms measuring up to 10 mm in diameter), and there were no other appropriate autologous veins for femorotibial artery bypass. There was no contralateral great saphenous vein, probably due to her history of varicose vein surgery (details unknown). In addition, since the bilateral short saphenous veins and arm veins were small in diameter, bypass surgery without using a varicose vein graft was impossible. Therefore, we decided to use the varicose vein graft for the bypass in order to salvage the limb instead of a prosthetic graft at the risk of infection. When the vein graft was gently distended with saline containing heparin using a syringe for preparation, the saccular venous aneurysm was partially resected (Fig. 2b, arrow). The remaining tortuous and dilatated varicose vein graft was used at its full length without splicing (Fig. 2b, arrowheads).
After the bypass surgery, the blood flow of the left lower limb improved significantly, and the ABI and SPP increased to 0.88 and 60 mmHg, respectively. Several debridement operations were required; finally, the stump of the amputated toes had completely healed by 6 months after the bypass surgery (Fig. 3a). The patient was followed regularly as an outpatient at intervals of 3 months for graft surveillance using duplex ultrasonography. However, even on follow-up computed tomography (CT), there were no signs of complications, such as occlusion or aneurysm of the varicose vein graft, during the 2-year follow-up period (Fig. 3b).
