Case study on peripheral arterial disease and its complications: Chronic limb threatening ischemia

Nivetha1, Anbarasi2

1Staff Nurse, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

Abstract

Chronic Limb-Threatening Ischemia (CLTI) is an advanced stage of peripheral arterial disease (PAD), characterized by chronic ischemic rest pain, non-healing ulcers, or gangrene in the lower extremities caused by severe obstruction of blood flow. It usually results from atherosclerosis and is commonly associated with diabetes mellitus, hypertension, and coronary artery disease.

Key words: Chronic Limb-Threatening Ischemia (CLTI); Peripheral Arterial Disease (PAD)

Case Presentation

A 68-year-old male presented with complaints of claudication pain in both calves for the past six months, more severe in the left leg. He had a history of paronychia over the left great toe, for which partial nail excision and incision and drainage were done three months ago. The wound did not heal and progressed to ulceration, followed by the development of rest pain.

Past Medical History:

  • Type II Diabetes Mellitus
  • Coronary Artery Disease – status post CABG 6 years ago
  • No known drug allergy

On Examination:

  • General condition: Conscious, oriented, afebrile
  • Vitals: PR – 82/min; BP – 140/66 mmHg; SpO₂ – 99% (room air)

Systemic:

  • RS – Bilateral air entry present
  • CVS – S1, S2 heard, no added sounds
  • P/A – Soft, bowel sounds present
  • CNS – No focal deficit

Local Examination:

  • Left great toe ulcer (1×0.5 cm) with slough on the medial aspect
  • Scar over left leg (Vein harvested for CABG)
  • Muscle wasting in the left foot
  • Bilateral upper limb and carotid pulses normal
  • Dorsalis pedis and posterior tibial pulses palpable post-procedure

Diagnosis

  • Left Lower Limb CLTI
  • Type II Diabetes Mellitus
  • Coronary Artery Disease (Post CABG)

Procedure Done

Left leg angioplasty performed on 04/11/2025 with good distal flow and palpable pulses after the procedure.

Pathology

CLTI results from progressive atherosclerotic narrowing and occlusion of peripheral arteries, leading to critical reduction in limb perfusion. In diabetic patients, endothelial dysfunction, hyperglycemia-induced vascular damage, and microvascular disease further impair healing and tissue oxygenation. Prolonged ischemia causes tissue necrosis, ulceration, and gangrene if untreated.

Signs and Symptoms

  • Claudication pain in lower limbs (left > right)
  • Non-healing ulcer on the great toe
  • Rest pain in the affected limb
  • Muscle wasting in foot
  • Diminished distal pulses before intervention
  • Relief of pain and improved pulsation after revascularization

Medical Management

Revascularization: Left leg angioplasty is done to restore blood flow.

Medications

Treatment TypeDrugsDoseFrequency
Antiplatelet therapyClopidogrel75 mgOD
Rivaroxaban2.5 mgBD
Statin therapyRosuvastatin20 mgOD
Antiplatelet & VasodilatorCilostazol50 mgBD
Beta-blockerNebivolol2.5 mgOD
Alpha-blockerTamsulosin0.4 mgOD
Mucolytic/AntioxidantN-acetylcysteine600 mgBD for 1 week

To continue regular anti-diabetic medication

Diet: Diabetic diet

Follow-up: Review after 15 days with vascular surgeon

Nursing Management

1. Assessment:

  • Monitor vital signs, limb color, temperature, and peripheral pulses.
  • Assess pain level using a pain scale.
  • Monitor puncture site for bleeding or hematoma.
  • Observe for signs of infection or ischemic changes in the limb.

2. Post-Procedure Care:

  • Maintain bed rest for 6–8 hours’ post-angioplasty.
  • Keep affected limb straight; monitor for bleeding at puncture site.
  • Encourage limb elevation and gentle movements after rest period.

3. Diabetic Management:

  • Monitor blood glucose levels regularly.
  • Ensure adherence to diabetic diet and medication.
  • Educate patient on foot care and hygiene.

4. Medication Administration:

  • Administer prescribed antiplatelet, vasodilator, and statin therapy.
  • Observe for side effects or drug intolerance.

5. Patient Education:

  • Advice on lifestyle modifications, smoking cessation, exercise, and diet.
  • Teach warning signs of ischemia and infection.
  • Emphasize the importance of regular follow-up.

Nursing Interventions

  1. Impaired tissue perfusion: Assess peripheral pulses and limb temperature; elevate leg slightly to improve venous return and detect changes early
  2. Pain related to ischemia: Administer analgesics as prescribed; maintain limb warmth which Enhances comfort and blood flow
  3. Risk of infection: Maintain sterile dressing over the ulcer and puncture site to prevent secondary infection
  4. Knowledge deficit: Provide health education on diabetic foot care and medication adherence Promotes self-care and prevents recurrence
  5. Risk for bleeding: Monitor puncture site; avoid strenuous movement post-angioplasty Prevents complications of procedure

Outcome

  • Rest pain relieved.
  • Palpable pulses in dorsalis pedis and posterior tibial artery post-angioplasty.
  • Ulcer showing signs of healing.
  • Patient clinically stable at discharge.

Patient Satisfaction and Feedback

The patient expressed satisfaction with the care provided. He reported significant relief from rest pain and appreciated the nursing team’s continuous monitoring, education, and support during hospitalization.

Evaluation

All expected outcomes were achieved:

  • Pain level reduced.
  • Improved peripheral circulation.
  • No postoperative complications observed.
  • Patient educated and compliant with discharge instructions.

Conclusion

Chronic Limb-Threatening Ischemia is a serious but treatable vascular condition when identified early and managed appropriately. A multidisciplinary approach involving surgical revascularization, medical therapy, diabetic control, and nursing care plays a crucial role in limb salvage and improving quality of life. Continuous follow-up and patient education are vital to prevent recurrence and ensure long-term recovery.

Evidence

Nightingale Journals

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