When Dr. Patrick Coffey first met Milton Salley in the Intensive Care Unit at Advocate South Suburban Hospital, Mr. Salley was in serious trouble. The 63-year-old couldn’t take a breath on his own and was dangerously close to losing his leg and his life.
Mr. Salley checked into Advocate South Suburban Hospital’s Emergency Department with severe COVID-19 the night before, as he realized it was getting more and more difficult for him to breathe. He also felt the sudden onset of pain in his right leg and foot, which was progressing to numbness and weakness in that foot and ankle.
During his workup in the Emergency Department for the acute right lower extremity symptoms, a CAT scan was performed. The scan showed Mr. Salley had an occlusion, or complete blockage, in the popliteal artery located behind the right knee. Dr. Coffey with Vascular Specialists was called immediately and when he reviewed the scan, he noted, “There was essentially no significant blood flow to the foot.” That morning, Mr. Salley also had incidents of atrial fibrillation, when the heart beats erratically. His health history included only obesity and a possibility of hypertension.
Mr. Salley was admitted to ICU and given a high flow nasal cannula, a supplemental oxygen therapy. This therapy creates a positive pressure environment within the respiratory system, opening the airways and dramatically increasing airflow, ventilation and oxygenation of the patient. High flow nasal cannula uses just two “nose plug” pieces attached to tubing that delivers oxygen. It is used to avoid the significantly more traumatic intubation, where a tube is inserted through the mouth and down into the trachea, resting at the top of the chest, below the dip in the throat.
Mr. Salley, who was not vaccinated against COVID-19, was experiencing COVID-19-associated coagulopathy. This presents as severe blood clotting or thrombosis, and is associated with embolic complications. These complications occur when pieces of clots from larger blood vessels break off and travel through the body to lodge in smaller vessels and block blood flow. Researchers now believe antiphospholipid antibodies are responsible for triggering the clotting, attacking the patient’s own body and increasing “stickiness” in the vascular system. These “rogue antibodies” also cause damage to the heart, lungs and brains of COVID-19 patients.
An acute cold leg happens when arteries providing oxygenated blood to the lower extremities - calves, ankles and feet - become blocked. “When a patient’s leg goes cold, there’s not a lot of wiggle room,” Dr. Coffey says. “There’s typically a 6-hour window to get treatment. Longer than that and the patient experiences severe damage to nerves and tissues, resulting in chronic health and mobility issues and often, amputation. Fortunately, Advocate South Suburban Hospital staff moved quickly. From the time of Mr. Salley’s scan to the moment we started the thrombectomy, we were within that 6-hour window.”
Mr. Salley’s abdominal aorta, the primary blood supply to the lower extremities, was also about 75% blocked with a 2 cm aortic thrombosis. “The cold leg was much more of an emergency at that point,” said Dr. Coffey. “With the severity of his illness, Mr. Salley was not able to withstand procedures to fix both issues, and treating his leg was the more urgent situation; without immediate treatment, Mr. Salley would have lost his leg.”
The operating room was prepped with the team standing by when, in consultation with Mr. Salley’s ICU health care providers and the anesthesiologist, everything went in a completely different direction. “When we went into ICU to take Mr. Salley to surgery, we all agreed he could not tolerate a move to OR, and he wouldn’t tolerate general anesthesia. The surgery was going to have to be done at the bedside, right in the ICU.”
The staff at Advocate South Suburban Hospital never blinked. “The intensivist, anesthesiologist and other staff were completely on board with the sudden change in plans,” says Dr. Coffey. “They totally agreed that doing a surgery in the ICU was in the best interest of the patient, and they immediately pivoted to make it happen.”
The OR staff was brought into ICU to Mr. Salley’s bedside, and he was given mild sedation. Because he could not tolerate lying flat due to difficulty breathing, Mr. Salley’s head was elevated. Local anesthetic was delivered to the locations where Dr. Coffey would be making incisions.
To perform the thrombectomy, Dr. Coffey made a small incision into the skin overlying the dorsalis pedis artery and another into the skin overlying the posterior tibial artery, at Mr. Salley’s ankle. For each artery, Dr. Coffey inserted a Fogarty® thrombectomy catheter and fed it through the vessel up behind the knee, beyond the clot. He then inflated the balloon and pulled it back, beginning to remove the clot and restore blood flow through each vessel. “After a few passes, we saw a significant increase in blood flow.”
“Mr. Salley was comfortable but alert and conversational throughout the entire procedure, something that has never happened before when I’ve done this surgery. After a few passes, he said, “Wow, my foot is already starting to feel better.” I turned to Jim, our surgical assistant, and said, “This is really awesome to receive instant feedback that the improvement is felt immediately,” said Dr. Coffey.
Dr. Coffey made more than fifteen passes with the Fogarty® catheter between the 2 arteries to ensure adequate healthy blood flow.
After restoring blood flow to the foot, Dr. Coffey made two incisions of about 8-10 centimeters in length on either side of Mr. Salley’s right lower extremity, performing prophylactic fasciotomies. “When we re-establish blood flow during a thrombectomy, the surrounding tissue gets a rush of blood flow and can quickly swell, creating acute compartment syndrome. This can lead to muscle and nerve damage. We find a fasciotomy prevents permanent damage to the extremity, protects limb function and also shortens recovery time.” These incisions were left open for decompression of these compartments of the leg, and then closed with delayed primary closure six days later.
Mr. Salley was able to leave the hospital after about 10 days with a prescription for Coumadin, an anticoagulant medication.
Most commonly, this procedure is performed with an incision behind the knee, but, Dr. Coffey says, “That is more invasive and uncomfortable, especially considering the very unique circumstances for this patient. When we access the blockage from the ankle, it requires smaller, less traumatic incisions.
Since then, Mr. Salley has been seen several times at the offices of Vascular Specialists in Tinley Park, Illinois where Dr. Coffey practices. “His incisions looked very good and while there was some swelling, overall the recovery was going well. There was a hematoma, old blood within the medial fasciotomy incision. We removed the sutures and decompressed the location and that old blood was removed. His leg has since healed very nicely with no residual deficit.”
The initial plan had been to treat Mr. Salley’s aorta when he was recovered and his kidneys were normalized, but a new CT scan revealed that the clot in the aorta had broken down naturally, requiring no intervention. “Mr. Salley now has good in-line blood flow, all the way down to his feet,” says Dr. Coffey.
Mr. Salley needed wound care to heal the fasciotomy for several weeks. This involved several appointments to drain, pack and wrap the wound to allow it to heal from the inside out. Mr. Salley also has some neuropathy down the path of the incision, but Dr. Coffey notes that is not unusual. “Mr. Salley has no limitations in function, and when physical therapy is completed, he should be fully recovered.”
Most patients who suffer from COVID-19-associated coagulopathy do not fair as well. These patients are typically admitted to ICU. Most require intubation and experience severe, life-changing side effects. Patients who develop COVID-19-associated coagulopathy have a very high associated mortality rate - over 47% of those with the complication will die.
While COVID-19 is not yet fully understood, severe life-threatening cases can overwhelmingly be avoided by getting vaccinated and receiving booster shots. In Mr. Salley’s age group, unvaccinated individuals are 4 times more likely to get COVID-19 than those who are vaccinated. The unvaccinated are 7 times more likely to require hospitalization than vaccinated individuals.
Mr. Salley realizes his unprecedented good fortune. “I am so blessed and so thankful for Dr. Coffey. I’m out of a wheelchair and not even using a walker. Everything is going real good. I feel like I made it over a very big fence that I wasn’t supposed to be on in the first place.”
Dr. Coffey says, “Doing a bedside surgery in ICU is absolutely not routine. It’s pretty crazy, but I didn’t give it a second thought and there was no pushback at all from Advocate South Suburban Hospital staff - never any feeling of “we can’t do this.” We were all just focused on the welfare of the patient. I thought, “We gotta do this to give this guy the very best chance.” - We were all on the same page and said, “Let’s make this happen and do the best we can in this circumstance to save this patient’s leg and life.” In the end, it was a very positive experience, we were able to provide the very best treatment, and the outcome has been very good for Mr. Salley.”
Mr. Salley agrees. “Dr. Coffey is a miracle worker and I am a miracle.”
