This is another installment in my “Peripheral Arterial Disease Hall of Shame” The photo is a 50ish woman with diabetes and a history of smoking. A right femoral popliteal bypass was performed 3 months earlier. Unfortunately she developed a graft infection and her groin wound opened up. When NPWT caused bleeding she required emergency vascular surgery. For the past 2 months she has ischemic rest pain and hangs her right leg over the side of the bed at night. Her pain is not controlled with a Fentanyl patch. Her SPP on the day of consultation at the wound center was 15 mmHg at the thigh, with a flat PVR. She has ischemic rubor of the right foot.
Although this lady’s ischemia had been recognized and an attempt made to revascularize her, she was discharged from the hospital with uncontrolled pain and without a clear follow up plan. While amputation is a sad outcome, allowing patients to suffer uncontrolled pain for months increases the likelihood of phantom limb pain after amputation. The day I saw her, I offered her emergency admission for pain control and possible amputation if no other options existed to improve her perfusion. She decided to return to her vascular surgeon.
Flat PVR
Photo 1: This is a completely flatPVR at the level of the thigh, which shows she has no pulsatile flow even in the femoral artery.
Right SPP thigh
Photo 2: She has a skin perfusion pressure of 15 mmHg at the thigh when a normal pressure at that level is more than 40 mmHg.
Photo 3: This is the classic look of an ischemic foot with ischemic rubor. Note her edema which she has because she keeps her feet down all the time.

Caroline Fife, MD    Twitter Facebook  |  LinkedIn