Team Work Saves a Leg

Bernice Smith of Maywood, Illinois, had lost her right leg due to complications from her diabetes, and now her left leg was in danger of amputation. Fifty-nine-year old Bernice has been living with diabetes since she was 26 years old and she was diagnosed with peripheral arterial disease (PAD) almost ten years ago.

It was her podiatrist, Dr. Ronald Sage, who first noticed that she had ischemia and non-healing ulcers in her left toes. Dr. Sage encouraged her to seek a vascular consultation. She was referred to cardiologist Dr. Robert Dieter, who felt there was a chance that her left leg could be saved.

"All patients with diabetes and PAD should see a podiatrist if they have any kind of foot abnormality," said Dr. Sage. "If they have a non-healing ulcer, as in Bernice's case, then they should go to the doctor immediately."

Diabetes is among the main risk factors for PAD, which can cause ischemia, gangrene, and, in severe cases, amputation. In the United States each year, diabetics undergo over 80,000 amputations. About half of those cases are partial foot amputations and half are amputations of the leg, either above or below the knee.

In Bernice's case, her right leg had become gangrenous and was amputated below the knee. When her left leg started to give her trouble, she sought out Dr. Sage.

"It was about two or three years ago that I started to have trouble with my legs," said Bernice. "It all started with a heart valve problem and got worse from there. I received a kidney transplant in 2003 and in 2006 I lost my right leg. I'm just so grateful to Drs. Sage and Dieter for helping to save my left leg."

Bernice had a procedure called balloon angioplasty in the major artery in her left thigh. This technique is very similar to the one performed by cardiologists to open narrow or clogged heart arteries. The procedure consists of inserting a catheter (a thin tube) inside a narrowed artery, and inflating a tiny balloon which is located the very tip of the catheter. Once Bernice's thigh artery was open, a stent (wire mesh tube) was inserted to keep the artery as wide open as possible. The procedure restored blood flow to Bernice's leg, which had started to turn gangrenous because it wasn't getting enough blood.

Bernice had many of the risk factors for cardiovascular disease. She has a family history of cardiovascular disease, smoked for over 40 years, and had had diabetes for over ten years. The artery in her left thigh had an extensive blockage that Dr. Dieter was able to open with the balloon angioplasty procedure, with which he achieves a success rate of 80-90% in similar patients.

"I met Bernice about a year ago when she needed coronary bypass surgery," said Dr. Dieter. "It was during a follow-up after her surgery that we noticed her left leg was ulcerated. If we hadn't been able to restore blood flow to her left leg, she would have had it amputated as well. In this case we were lucky."

Smoking is a big risk factor for PAD. It has been shown to accelerate the progression of both PAD and diabetes. In Bernice's case, it was Dr. Dieter who persuaded her to stop smoking after 40 years.

"He told me in so many words that if I don't give up smoking I was going to die. That was all it took for me to stop on the spot," said Bernice. "I handed him my pack of cigarettes right then and haven't smoked since."

Diabetes is among the main risk factors for PAD, which is similar to coronary artery disease: Fat deposits clog the arteries outside the heart or brain, restricting blood flow to arms, legs, intestines, or kidneys. Because PAD often affects the leg arteries, early symptoms include pain in the legs while walking. In the most severe cases, PAD can cause critical limb ischemia (severe obstruction of the arteries which seriously decreases blood flow to the extremities), which can result in gangrene, amputation, or death.

While they were able to save Bernice's leg, they did need to amputate several of her toes due to gangrene, which had caused permanent tissue damage. Bernice recovered quickly and was up and walking within a few weeks. In addition to the prosthesis she uses for her right leg, she now has prosthetic toes which enable her to walk with a walker or cane. She uses a wheelchair only if she needs to go more than a block.

"I walk every chance I get, I don't like being in a chair all the time," said Bernice. "After the procedure, I could feel the blood flow. It felt like it was a normal leg again."