Chronic Limb Ischemia due to Peripheral Arterial Disease This case presentation discusses an 80-year-old male farmer with a significant history of chronic smoking and alcohol use, presenting with progressive ischemic symptoms in the left foot. Over one month, the patient experienced worsening pain—initially intermittent claudication that rapidly progressed to rest pain. Additionally, he developed blackish discoloration of the 4th and 5th toes, consistent with dry gangrene, ultimately leading to amputation. On examination, features of chronic limb ischemia were evident, including thin shiny skin, loss of subcutaneous fat and hair, brittle nails, and a non-healing ulcer at the site of amputation. Vascular tests indicated severe arterial insufficiency: reduced Buerger’s angle, delayed venous refilling time, colder limb temperature, and absent oscillatory movement in Fuchsig’s test. The ulcer had classical features of an ischemic ulcer—punched out margins, pale granulation tissue, and dry necrotic surrounding skin. Systemic examination was unremarkable, and there was no evidence of neuropathy or systemic infection. The provisional diagnosis was chronic limb ischemia secondary to infrafemoral atherosclerotic occlusion, confirmed by Doppler and angiographic studies. Management focused on conservative and medical therapy, given the patient’s age and comorbidities. Treatment included strict smoking cessation, limb care, graded exercise, and risk factor control with statins, antiplatelets (aspirin, clopidogrel), and vasodilators (cilostazol, pentoxifylline). Glycemic and hypertensive control were emphasized. This case highlights the classical clinical progression of Peripheral Arterial Occlusive Disease (PAOD) and underscores the importance of early identification, risk modification, and appropriate wound care to prevent limb loss in vulnerable populations

1. CLINICAL CASE DISCUSSION OF
SURGERY B UNIT
PRESENTER - DR DARSHAN S BANE

2. PATIENT DETAILS
• Name :- Nanjaiah
• Age :- 80 years
• Sex :- Male
• Occupation:- Farmer
• Address :- K R Pete
• Education:- No formal education
• Socioeconomic status(SES) :- Lower middle class(according to
modified Kuppuswamy scale)
Date of admission: 23/02/2025

3. PRESENTING COMPLAINTS
• C/O pain in the left foot from past 1 month.
• C/O blackish discoloration of 4th
and 5th
toes of left
foot since 1 month.

4. HISTORY OF PRESENTING ILLNESS :
• Here is a chronic smoker who was apparently alight 1 month back
when he started experiencing pain in his left foot which was insidious
in onset and progressive since then. At the onset, patient used to
experience cramping pain in left foot after walking for about 1-2 kms
but he could continue to walk inspite of the pain. After about 1/2
month, he started having pain even after walking 200-300m and had to
take rest to get relief.
• For the past 7-10 days, patient has been experiencing continuous dull
aching pain in the left foot and toes even at rest, which is severe in
intensity and continuous aching in nature. It is more at night and
wakes him up from sleep.

5. • He has to hang his legs by the side of his bed which gives him partial relief
from the pain. Patient took medication from local dispensary for the pain
but it failed to provide any relief. There is no such pain in the left calf,
thigh, left buttock, or the right lower limb. No h/o numbness, paresthesia.
• Patient also complains of blackish discolouration of left 4th
and 5th
toe
spontaneous in onset initially involving the tip of the toe and gradually
progressed to involve the whole toe over a period of 15-20 days, it is not
associated with discharge. He has undergone amputation of the same toes
after admission.
• No h/o trauma, ulceration or pustule formation before the onset and gangrene.
• No h/o application of any irritants or excessive heat
• No h/o edema, fever, foul smelling discharge

6. • Patient is a chronic smoker for past 60 years of his life.
• No h/o fever, redness or pain in front of the leg.
• No h/o TIA, CVA( Loss of consciousness, weakness of limbs, asymmetry of face ,
giddiness).
• No h/o fainting, transient blackouts, blurred vision.
• No h/o chest pain, breathlessness.
• No h/o post prandial pain abdomen.
• No h/o impotency.
• No h/o pain in buttocks and thigh.
• No h/o polyuria, polydipsia or polyphagia.
• No h/o consumption of ergots.
• No h/o Raynaud’s phenomenon.
• No h/o pain, weakness or paresthesia in upper limb.

7. PAST HISTORY
• No h/o similar complaints in the past.
• No h/o HTN, T2DM, TB, epilepsy, asthma, thyroid disease.
• No h/o any surgeries in past.
• No h/o previous hospitalization or any medical intervention.
• No h/o collage vascular disease.

8. PERSONAL HISTORY
• Diet- mixed.
• Appetite – normal
• Disturbed sleep due to pain since past10 days.
• Regular bowel and normal bladder habits
• Habits
• Chronic smoker – consumes 2 pack (48) beedis per day since past 60 years (SI-2880;
PYI-120)
• No h/o tobacco chewing.
• Alcoholic- 180 ml wishkey/day (60 g), for past 60 years.

9. • FAMILY HISTORY
• No H/o similar complaints in the family.
• DRUG HISTORY
• Patient is not on regular medication for any comorbid illness.
• ALLERGIC HISTORY
• Patient is not allergic to any of known drug.

10. SUMMARY
Here is a 80 year old gentleman, smoker and alcoholic since for past 60
years, presented with intermittent claudication in the left foot for the
past 1month, with progressive decrease in the claudication distance and
has now progressed to rest pain. There is also history suggestive of
gangrenous changes of 4th
and 5th
left toes, which is painful and not
associated with any discharge or systemic symptoms with no significant
past or family history.

11. GENERAL PHYSICAL EXAMINATION
• Here is elderly male patient moderately built and nourished; he is
conscious, co-operative and well oriented to time, place and person.
• Height – 155cm
• Weight – 43kg
• BMI – 17.9 kg/m2
• Head to Toe examination
• No pallor, icterus, cyanosis, clubbing or edema.

12. VITAL SIGNS
• PULSE RATE – 90 beats/min, with regular rhythm, normal volume
and character measured in the left radial artery, condition of vessel
wall -normal, with no radioradial or radiofemoral delay.
• BLOOD PRESSURE –
• 160/90mm of Hg measured in left brachial artery in supine position.
• 140/80 mm Hg measured in right brachial artery in supine position.
• RESPIRATORY RATE – 16cpm
• TEMPERATURE – Afebrile(98.7°F)
• SP02 98 % at room Air

13. LOCAL EXAMINATION
• Patient examined in broad daylight in a well-
lit room, after taking informed consent with
adequate exposure.
• Patient is examined in sitting and supine
postion.
• Attitude: patient is sitting with left knee and
hip flexed on bed holding the foot in both the
hands.

14. INSPECTION
EXAMINATION OF LEFT LOWER LIMB
• Gait- patient limps (antalgic gait) on
walking.
• No visible deformity, pulps of toes are
flattened.

15. • An approximately 6cm x 5cm
solitary ulcer is noted over the
base of amputated site of 4th
and
5th
toes, extending from lateral
border of foot to base of 3rd
toe,
oval in shape, floor made of pale
granulation tissue with islands of
slough and with regular margins
and punched out edges, no
discharge. Surrounding skin
appers black and dry.

16. • Proximal part of limb to gangrenous area-
• No redness, ulcer, scars or sinuses.
• Colour- no pallor or congestion of the limb, no black patches or skip lesions.
• Veins over the leg are well filled and prominent in lying down position over
anterior aspect of leg.
• Skin over the foot and leg appears - thin and shiny, with loss of subcutaneous
fat, loss of hair till mid thigh.
• Nails are brittle with transverse ridges.
• No varicosities of GVS or SSV
• Second and third toes appear shiny, edematous with purpulish discoloration.
• Left calf and thigh muscle appear wasted.

17. TESTS IN INSPECTION
• BUERGER’S POSTURAL TEST (angle of circulatory insufficiency):
Pallor couldn’t be made out due to dark complexion.
Guttering of veins seen at 20-30° to horizontal plane
• CAPILLARY FILLING TIME:
Couldn’t be made out due to dark complexion of skin
• VENOUS REFILLING TIME:
Refilling of veins present >30seconds

18. EXAMINATION OF RIGHT
(ASYMPTOMATIC) LOWER LIMB:
• Nails are brittle.
• Thin shiny skin with loss of hair till mid thigh.
• No discoloration or ulcer .
• No focal varicosities.
• Buerger’s angle = pallor and guttering of veins seen at 60 degree
elevation.
• Capillary refill time = normal
• Venous refilling time = normal

19. PALPATION
• Skin Temperature –colder compared to opposite limb uptill mid thigh.
• Tenderness present at base of ulcer and surrounding skin.
• A 6cm x 5cm solitary oval shaped ulcer is noted over the base of
amputated site of 4th
and 5th
toes, extending from lateral border of foot
to base of 3rd
toe, floor made of pale granulation tissue with islands of
slough, and regular margins with punched out edges, base is formed
by underlying soft tissue, no discharge. Surrounding skin appers black
and dry and tender.
• Capillary refilling time - Could not be appretiated.

20. • Venous refilling time – increased (30seconds)
• Crossed leg test (Fuchsig’s test) - no oscillatory movements of left leg
seen.
• Limb above the gangrenous area
• No edema or crepitus.
• No tenderness along the line of arteries.

21. PERIPHERAL PULSES
SITE Right LEFT
SUPERFICIAL TEMPORAL ++ ++
CAROTID ++ ++
SUBCLAVIAN ++ ++
AXILLARY ++ ++
BRACHIAL ++ ++
RADIAL ++ ++
ULNAR ++ ++
FEMORAL ++ +
POPLITEAL ++ -
ANTERIOR TIBIAL ++ -
POSTERIOR TIBIAL + -
DORSALIS PEDIS + -

22. MOTOR SYSTEM
BULK OF MUSCLE
TONE
CIRCUMFERENCE Right LEFT
MID THIGH 39 cm 36 cm
MID CALF 28 cm 26 cm
TONE Right LEFT
UPPER LIMB NORMAL NORMAL
LOWER LIMB NORMAL NORMAL

23. POWER
REFLEXES
POWER Right LEFT
UPPER LIMB 5/5 5/5
LOWER LIMB 5/5 5/5
REFLEXES Right LEFT
ANKLE 2+ 2+
KNEE 3+ 3+

24. • EXAMINATION OF SENSORY SYSTEM
• Pain, touch, temperature and Proprioception- normal
• EXAMINATION OF REGIONAL LYMPH NODE
• Single palpable lymph node in left horizontal inguinal group of lymphnodes .
• EXAMINATION OF JOINTS:
• Right – normal
• Left – ankle –normal
• Toes – restricted.

25. SYSTEMIC EXAMINATION
• CARDIOVASCULAR SYSTEM : S1, S2 heard , no murmurs
• RESPIRATORY SYSTEM :Bilateral normal vesicular breath sounds
heard , No added sounds.
• CENTRAL NERVOUS SYSTEM : Conscious , oriented , no focal
neurological deficits.
• PER ABDOMEN : soft , Non-Tender , No organomegaly, BS-present

26. PROVISIONAL DIAGNOSIS
• CHRONIC LIMB ISCHEMIA OF LEFT LOWER LIMB
SECONDARY TO INFRAFEMORAL BLOCK SECONDARY TO ?
ATHEROSCLEROSIS WITH NON-SPECIFIC ARTERIAL ULCER
(DRY GANGRENOUS) OVER LEFT 4TH
AND 5TH
TOE
AMPUTATION SITE.

27. Investigations
• CBC
• RFT
• LFT
• RBS, HBA1C
• Lipid profile
• ECG and Echo
• Duplex doppler
• Angiography – CT angiogram, MR angio

30. Treatment
• Stop smoking
• Exercises- regular controlled walk
• Diet
• Care of limbs
• Diabetic and HTN control
• Antilipid drugs – Atorvastatin 10mg, Pravastatin 40mg
• Low dose aspirin 75mg
• Antiplatelets – clopidegrol
• Vasodilators – Ticlopidine, dipyridamole, cilostazle 100mg BD
• Pentoxifylline 400mg TID.