Peripheral Arterial Disease (PAD) Expert Forum
Urgency of surgery before loss of toes might begin?
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Questions in the Peripheral Arterial Disease forum are answered by Dr. Lee Kirksey, associate professor at The University of Pennsylvania School of Medicine. Topics covered include abdominal aortic aneurysm , amputation, arteriovenous fistula, atherectomy, carotid artery surgery , cholesterol , claudication, deep vein thrombosis (DVT) , endovascular aortic stent graft (EVAR), stent placement , stroke prevention, varicose veins , and venous insufficiency .

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Urgency of surgery before loss of toes might begin?

My husband has severe PAD with the superficial femoral artery occlusion the entire length in his left leg (angiogram results) with first 3 toes afftected and non-healing ulcers on the big toe starting on second toe now.  No infection yet but severe pain also toes are bluish-purple color and more blisters developing.  He's under the care of a Vascular surgeon at Harborview Hospital.  He's seen two other Vascular surgeons that both felt time is of the essence and that his pain and toes will heal as soon as blood flow is repaired with by-pass.  His current surgeon seems to be in no rush and it looks like surgery may not be done for at least 3 to 4 weeks if not longer.  He also thinks the surgery won't fix his toes or relieve his pain thinking it's neuropathy which after much study and the previous Dr.s opinion we know it isn't.  My husband is diabetic however it's well controlled with oral meds and diet.  His most recent AIC was 6.3.  My question is with how I've described his toes how long must this drag on before he will possibly lose his toes?  Also he had an ABI on 3/2/09 which showed right was 0.9 and lt was 0 but when we went to the ER on 4/1 they said his left was 0.6 and his toes were much worse?  Is it possible whoever was checking was wrong?  I know they couldn't find a pulse with their fingers and he'd had this checked 3 times prior in March it makes no sense to me anyway.

Thank you,
Tina & Denny
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Hello
I apologize for the delayed response. I have a couple of questions and remarks about your husband's problem. First, there are different type of indexes. There is an ankle brachial index and a toe brachial index. In general, for diabetics, the ABI may be less reliable because of the presence of calcification making the vessel noncompressible. The TBI is more reliable and should be greater than .6. Secondly, it is quite uncommon to have poor circulation to the extent that it causes a toe ulceration, from a superficial femoral artery blockage in the absence of other blockages below the knee. Conversely, it is not uncommon that a diabetic because of the way shoes fit or for other reasons, develops an ulcer and then the mild to moderate impairment caused by that type femoral artery blockage-prevents the ulcer from healing.

Secondly, it is not uncommon to develop neuropathy in the toes, even in the presence of tight blood glucose control.

In any case, when ulcers are present and there are no signs of uncontrolled infection, operation is commonly performed as soon as reasonably possible. this is usually after heart tests demonstrate that the patient can tolerate an operation. The other consideration, is to know if there is any minimally invasive procedure that can be done to re establish blow flow (like angioplasty, stenting or atherectomy) instead of surgery

I'm a little confused as to why he's seen three surgeons and you seem to be at odds with the most recent VS who appears to have the final decision.. I would request a meeting with your surgeon to discuss your concerns. As you know, it is very complex and every bit of detailed information (much of which I dont have) is important. Perhaps a discussion will allow your doctor to better explain his decision not to proceed immediately

Good luck and Best of health
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Lee Kirksey, MDBlank
The Cleveland Clinic Foundation
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