Complicated leg wounds following distal bypass surgery

A 76-year-old lady with type 2 diabetes of 30 years' duration underwent a distal bypass for critical ischaemia. Three days later the proximal area of her leg wound developed bluish discolouration (Fig. 6.28a). The next day it began to break down (Fig. 6.28b) and then dehisced, revealing an area of yellow slough (Fig. 6.28c). Wide-spectrum antibiotics were prescribed. The area dried out and formed a dark brown eschar which stood proud of the area of skin. The vascular surgeon agreed that if debris accumulated in this area it should be gently debrided in the diabetic foot clinic and this was done weekly on three occasions.

When she next came to the foot diabetic clinic for her routine weekly appointment, and the dressing was taken down, the eschar on the leg was seen to be gently vibrating at the same rate as the patient's pulse. The patient was taken to theatre for an emergency procedure. The artery underlying the eschar ruptured as she was being lifted onto the operating table: even though the surgeons were fully prepared there was considerable blood loss. The artery was repaired and the leg healed in 4 months (Fig. 6.28d).

Key points

• Pulsating wounds of distal bypass surgery should be referred as an emergency to the vascular surgeon

• Patients whose bypass leg wounds become infected are at great risk of losing the graft

■ Outpatient debridement of leg wounds should be performed with great caution

• Leg wounds from distal bypasses should be inspected weekly until fully healed.

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