The diabetic foot that almost wasn't saved

58-year-old man from Ludhiana, T2DM for 15 years, presented with a black great toe on the right foot, rest pain for four weeks, and an outside recommendation for below-knee amputation. He drove long-haul trucks for a living — the amputation was, effectively, the end of that living.

Ankle-brachial index (ABI) 0.32 on right. Duplex confirmed superficial femoral artery occlusion with reconstitution below the knee via collaterals. CT angiography confirmed patent tibioperoneal trunk and single-vessel run-off to the foot via the peroneal. Wound-care team assessed the toe as salvageable if flow was restored within days.

Below-the-knee angioplasty of the tibial and pedal arteries, angiosome-directed to the great-toe territory. The alternative — a distal bypass — was possible but higher morbidity in a patient still smoking. Angioplasty was the reasonable first attempt with bypass held in reserve.

Antegrade femoral access. Sub-intimal recanalisation of a 15-cm SFA occlusion; drug-coated balloon of the tibial segment. Foot-vessel angiography confirmed direct pedal flow at completion. Time from Ludhiana clinic visit to angioplasty: 48 hours.

Toe demarcation and auto-amputation of the distal phalanx; the rest of the foot healed. ABI improved to 0.78. Back driving trucks at 3 months. The remaining phalanx is not what a foot looked like before — but it is a foot, and it walks.