Management of Bilateral Acute Lower Limb Ischemia in Patients with Prolonged International Normalized Ratio and Thrombocytopenia

Abstract Atrial fibrillation (AF) is a major risk factor for thromboembolic events, including acute limb ischemia (ALI). We report a case of bilateral ALI in a 52-year-old male with AF, complicated by prolonged international normalized ratio (INR), thrombocytopenia, and multiorgan dysfunction. The patient initially presented with AF with rapid ventricular response, severe left ventricular dysfunction, and risk factors including hypertension, diabetes, and prior stroke. Rate control with amiodarone and anticoagulation was initiated. However, the patient developed acute liver injury, renal dysfunction, prolonged INR (5.88), and thrombocytopenia (56.000/uL), followed by bilateral lower limb ischemia due to bilateral tibialis anterior arterial occlusion. Standard revascularization posed high bleeding risks. Supportive therapies to stabilize liver and renal function were prioritized, and anticoagulation was modified. Once INR decreased below 3.0 and platelet count improved above 75.000/uL, percutaneous thrombo-aspiration was performed, successfully restoring blood flow and preventing further limb loss. This case highlights the importance of individualized management for ALI in AF patients with very high bleeding risk, emphasizing treating underlying organ dysfunction, and cautious timing and type of revascularization.