This case panel discussion addresses some of the problems and judgment decisions required in a patient with extensive forefoot gangrene, a stenosis of the superficial femoral artery (SFA), and occlusions of all three leg arteries in the mid and upper leg. With extensive foot debridement to the transmetatarsal level, balloon angioplasty of the SFA, and a vein bypass to the distal anterior tibial artery, a functional foot remnant was saved. The timing of the various procedures, technical details

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... egarding them, and other issues are discussed. A 49-year-old diabetic, hypertensive man presented with right foot gangrene. He has had progressive infection and tissue loss of the right foot over the past two months, despite surgical debridement, oral, and intravenous antibiotics, and was offered below-knee amputation at an outside hospital. He denies rest pain or claudication. He has had diabetes for 15 years, which is currently poorly controlled on oral agents, and he takes one antihypertensive medication. He is a non-smoker and has no history of hyperlipidemia. ,p; 2000,12,2,131,150,ftx,en;pvs00075 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. On physical examination, he was afebrile. Femoral pulses were 3+ (out of 4) bilaterally, the left popliteal pulse was 2+, and the left pedal pulses were 1+-2+. The affected right leg had no distal pulses, only monophasic Doppler signals were present in the posterior tibial and dorsalis pedis. The pedal arteries were non-compressible and the transcutaneous oxymetry value (T c P0 2 ) was 41 mmHg at the right forefoot with a decrease to 35 after 3 minutes of elevation. Light touch and sensation were diminished in both feet. There was severe wet gangrene of the distal plantar forefoot with gangrene of the second and third toes (Figs. 1A,B) .