Cardiovascular · Moderate
This case is fictional and exists for study. It describes no real patient.
68 years · male
A 68-year-old male presents with a 6-month history of right calf pain that occurs after walking 100 metres and resolves within 5 minutes of rest. Over the past 3 weeks, he reports a continuous burning pain in his right forefoot that wakes him at night and is partially relieved by hanging his leg over the side of the bed. His medical history includes type 2 diabetes mellitus, hypertension, and a 35 pack-year smoking history. Physical examination reveals a cold, pale right foot with a 1 cm superficial ulcer over the first metatarsal head. Femoral pulses are palpable bilaterally, but popliteal, dorsalis pedis, and posterior tibial pulses are absent on the right.
Vital signs
- HR
- 76 bpm
- BP
- 145/88 mmHg
- RR
- 16/min
- Temp
- 36.6 °C
- SpO₂
- 97%
Examination findings
- Right lower limb: cool, pale, capillary refill time 4 seconds
- Absent right popliteal, dorsalis pedis, and posterior tibial pulses
- Superficial 1 cm non-healing ulcer over right first metatarsal head
Investigations
| HbA1c | 62 mmol/mol | reference: 20-42 |
| eGFR | 78 mL/min/1.73m2 | reference: >90 |
| Total Cholesterol | 6.2 mmol/L | reference: <5.0 |
Question 1 of 3
Which of the following is the most likely diagnosis?
Chronic limb-threatening ischaemia (CLTI) is characterized by peripheral arterial disease accompanied by ischaemic rest pain (typically worse at night and relieved by dependency) and/or ischaemic tissue loss (ulceration or gangrene) present for more than 2 weeks. Acute limb ischaemia presents abruptly within hours to days ('6 Ps'). Intermittent claudication presents with exertion-induced pain relieved by rest without rest pain or ulceration. Venous stasis ulcers are typically moist, minimally painful, located in the gaiter area, and accompanied by venous stigmata (e.g., hyperpigmentation, varicose veins).
Teaching point: Chronic limb-threatening ischaemia is defined by peripheral arterial disease with ischaemic rest pain, ulceration, or gangrene lasting more than two weeks.
Question 2 of 3
Which of the following is the most appropriate initial bedside investigation to assess the severity of peripheral arterial disease in this patient?
Ankle-brachial pressure index (ABPI) is the primary non-invasive bedside investigation used to confirm the presence and severity of peripheral arterial disease. Duplex ultrasound and MRA are anatomical imaging studies used later to localize lesions and plan revascularisation. Catheter digital subtraction angiography is an invasive modality reserved for therapeutic interventions or complex pre-procedural planning.
Teaching point: Ankle-brachial pressure index (ABPI) is the first-line initial bedside test for diagnosing and staging peripheral arterial disease.
Question 3 of 3
Which of the following is the most appropriate next management step for this patient?
Patients presenting with chronic limb-threatening ischaemia (rest pain and tissue loss) require urgent vascular surgical referral for assessment of revascularisation (endovascular or surgical bypass) to save the limb. Supervised exercise therapy is indicated for stable intermittent claudication but is ineffective and contraindicated as monotherapy for CLTI. Medications like pentoxifylline or cilostazol are second-line symptomatic measures for claudication, not CLTI. Delaying referral with routine podiatry risks limb loss.
Teaching point: Chronic limb-threatening ischaemia requires urgent referral to vascular surgery for revascularisation assessment to avoid limb amputation.
Key learning points
- Ischaemic rest pain (worse at night, relieved by hanging the leg down) combined with tissue loss defines chronic limb-threatening ischaemia.
- ABPI measurement is the initial bedside test to establish the diagnosis and severity of peripheral arterial disease.
- Chronic limb-threatening ischaemia requires urgent vascular surgical assessment for revascularisation alongside cardiovascular risk reduction.
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