Bilateral Acute Limb Ischaemia Following Myocardial Infarction in a Patient With Left Ventricular Thrombus and Severe Peripheral Arterial Disease

A 69-year-old woman presented with sudden severe bilateral lower-limb pain and paraesthesia one week after an episode of severe chest pain.Examination demonstrated bilateral pallor, cold limbs, profound sensory loss, absent distal pulses and left foot motor deficit.She was hypotensive and hypothermic, with a blood pressure of 88/55 mmHg and lactate of 3.5 mmol/L, raising concern for severe acute limb ischaemia (ALI).Computed tomography (CT) angiography demonstrated extensive bilateral arterial occlusion with acute and chronic features, including acute-appearing thrombus at the right common femoral bifurcation and further superficial femoral and popliteal occlusions bilaterally.No acute aortic syndrome was identified.Cardiac investigations showed ST-segment elevation on her electrocardiogram (ECG), troponin greater than 7000, severe left ventricular (LV) systolic dysfunction (ejection fraction less than 35%) and an LV thrombus.The recent myocardial infarction, LV thrombus and fresh clot retrieved at embolectomy supported a cardioembolic mechanism.The patient received unfractionated heparin and was transferred urgently to a tertiary vascular centre, where bilateral Rutherford IIb ALI was diagnosed.She underwent bilateral common femoral and right popliteal embolectomies with bilateral fasciotomies.Fresh thrombus was retrieved, although the right anterior compartment was non-viable.She subsequently recovered and was discharged on apixaban, aspirin and bisoprolol.This case highlights the need for rapid recognition and treatment of bilateral ALI, consideration of cardiac embolism following myocardial infarction, exclusion of acute aortic pathology and urgent anticoagulation and revascularisation.It also demonstrates that acute thromboembolism can occur on a background of severe chronic peripheral arterial disease, producing a complex multifactorial presentation.