Vascular Awareness as the Key to Limb Salvage in Diabetes Mellitus

Background: Foot ulcers in patients with diabetes mellitus are not always caused by microvascular complications. Some cases represent chronic limb-threatening ischaemia (CLTI), which carries a high risk of major amputation and mortality. Vascular awareness is essential to prevent misdiagnosis and to enable limb salvage strategies. Case Report: A 54-year-old man with poor health-seeking behavior was newly diagnosed with diabetes mellitus in December 2024 after the appearance of a right foot ulcer. The wound continued to enlarge despite three weeks of treatment, leading to referral to a cardiologist. Evaluation revealed atrial fibrillation and heart failure with reduced ejection fraction (EF 31%). Physical examination showed a cold, pulseless right limb, although motor–sensory function was preserved. Doppler ultrasonography demonstrated complete popliteal occlusion, and angiography confirmed thrombotic occlusion from the proximal superficial femoral artery to the proximal anterior tibial artery, with distal perfusion dependent on tibioperoneal collateral arteries. Catheter-directed thrombolysis (alteplase 0.5 mg/h for 24 hours with low-dose heparin) followed by balloon angioplasty (3.5 × 120 mm and 4.0 × 150 mm) of the popliteal and proximal anterior tibial segments successfully restored distal flow. Through multidisciplinary collaboration, progressive wound healing was achieved, and major amputation was avoided. Conclusion: This case highlights that vascular awareness in non-healing diabetic foot ulcers, together with multidisciplinary collaboration is the key to achieving limb salvage.