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Abstract: The patient Mr. Liu had a long history of heavy smoking, repeated lower limb pain and toe ulceration, which did not heal for a long time, and he was transferred to many parties for many years, and the efficacy of treatment did not meet expectations. He was most recently diagnosed with thrombo-occlusive vasculitis, combined with right lower limb occlusive vasculitis with gangrene, and underwent surgery, after which he developed redness and pain in the right lower limb toe and local ulceration and pus, so he came to our hospital. After corresponding treatment, the patient’s condition was significantly controlled, and all indicators improved.
Basic information】Male, 38 years old
Disease Type】Thrombo-occlusive vasculitis
Hospital】The First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine (Zhejiang Hospital of Traditional Chinese Medicine)
Time of consultation】February 2022
Treatment plan】Medication (general dispersion + injectable parecoxib sodium + injectable cefoperazone sodium sulbactam sodium) + surgical treatment (infrapopliteal artery balloon dilatation angioplasty + debridement toe amputation + closed negative pressure drainage of the wound)
Treatment period】3 months of hospitalization
Treatment effect】The condition has been significantly controlled, and all indicators are improving
I. Initial consultation
Patient Mr. Liu came to our department and reported that he had right lower limb discomfort without obvious cause 5 years ago, usually felt sore and swollen after walking 1000 meters, and needed to stop and continue walking. After treatment, the patient felt better than before and his symptoms disappeared. In July 2021, the patient underwent an amputation of the second toe of the right foot due to necrosis of the second toe of the right foot, and in January 2022, the patient developed blackness of the third toe of the right foot with pain and pus without any obvious cause, and went to an outside hospital. In February, the patient’s right lower extremity toe became red, swollen and painful, accompanied by local ulcers and pus, and for further treatment, he was admitted to our hospital as an outpatient.
II. Treatment process
After admission, the patient was examined, and the results showed that the patient had necrosis of the 3rd-5th toes of the right foot, the skin was blackened, purulent exudation was visible between the toes, the 2nd toe was absent, the right lesser toe was red and swollen with local ulceration, the local skin of the right dorsal foot was pale, the skin temperature was low, and the dorsal foot artery could not be palpated. The patient was later examined for routine blood tests, which showed high levels of white blood cell count and absolute neutrophil count. Blood biochemical examination showed glucose of 6.78 mmol/L, creatinine of 57 μmoI/L, urea of 2.5 mmol/L, direct bilirubin of 9.5 μmoI/L, glutamate transaminase of 70 U/L, and gamma-glutamyl transpeptidase of 61 U/L. The patient’s liver and kidney function tests showed glucose of 7.69 mmol/L, creatinine of 58 μ moI/L, total protein was 64.5 g/L, and albumin was 39.8 g/L.
A chest CT examination was performed, and the results showed multiple scattered chronic inflammation with foci of fibrosis in both lungs and localized thickening of the pleura on both sides of the patient. At the same time, ultrasound examination of the lower extremities was performed, and the report showed hypoechoic filling in the posterior tibial and peroneal arteries of the right lower extremity, which was considered thrombosis. The deep vein of the right lower extremity showed a clear flow. Later, arteriography of the lower extremity was performed, which showed that the patient’s right peroneal artery was faintly visualized with a small lumen, the right anterior and posterior tibial arteries were occluded, and the lumen of the right peroneal artery was locally narrowed, and the right calf-foot subcutaneous vein was visualized, which was diagnosed as thromboembolic vasculitis.
Subsequently, the patient’s trauma condition and arterial blood supply of the lower extremity continued to be evaluated, and it was decided that the patient should first undergo balloon dilatation and angioplasty of the infrapopliteal artery to unblock the blood vessels, and then perform debridement and toe amputation when the blood supply of the toe was restored. At the same time, the granulation was cultured after debridement, and closed negative pressure drainage of the wound was considered after the granulation was fresh. After the operation, the patient was given the Chinese medicine formula General San to apply externally to activate blood circulation, disperse blood stasis and drain pus, and was also given injectable parecoxib sodium and injectable cefoperazone sodium sulbactam sodium for symptomatic treatment.
III. Treatment effect
After the treatment, the patient’s condition was controlled. Although the postoperative dorsalis pedis artery pulsation was still slightly weaker than the healthy side, it recovered well compared with the preoperative side. From the results of the auxiliary examination, the patient’s routine blood test and biochemical test showed that the values of white blood cell count, creatinine, urea, direct bilirubin, glutamate transaminase and gamma-glutamyl transpeptidase had returned to the normal range. After 3 months, the patient met the discharge criteria and was discharged from the hospital.
IV. Notes
We are glad that the patient’s condition has improved after a series of aggressive treatments. However, in view of the patient’s long-term history of excessive smoking, the tendency of progressive aggravation of lower limb ischemic symptoms several times during the course of the disease, and the accompanying symptoms of resting pain and intermittent claudication, the patient needs to pay attention to the following points in daily life.
1. Patients should quit smoking and drinking in daily life, develop good habits of life and rest, eat a light and low-sugar diet, take appropriate supplements, and pay attention to monitoring blood sugar.
2. Patients should pay attention to monitoring their own condition in daily life, and once infection or other uncomfortable symptoms appear, they should go to the hospital promptly for early treatment.
V. Personal insight
Thrombo-occlusive vasculitis is a multidisciplinary, multi-disciplinary comprehensive work, mostly in the male population of long-term smoking, and the disease has a long course, the treatment is more complex, this patient is also due to years of seeking medical treatment for a long time and came to see the doctor, but fortunately the final result is more satisfactory. After the onset of the disease, the clinical condition of most patients is prone to recurrence, the treatment of drug therapy alone is often not ideal, and surgical treatment in most cases is also accompanied by the shortcomings of a long course of disease, so the disease is more difficult.