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.

Keywords

acute limb ischemia - atrial fibrillation - prolonged INR - thrombocytopenia - acute liver injury - acute kidney injury - revascularization

Publication History

Received: 03 July 2025

Accepted: 27 October 2025

Article published online:
14 November 2025

• References

• 1 Van Gelder IC, Rienstra M, Bunting KV. et al; ESC Scientific Document Group. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45 (36) 3314-3414
• 2 Menke J, Lüthje L, Kastrup A, Larsen J. Thromboembolism in atrial fibrillation. Am J Cardiol 2010; 105 (04) 502-510
• 3 Mazzolai L, Teixido-Tura G, Lanzi S. et al; ESC Scientific Document Group. 2024 ESC guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45 (36) 3538-3700
• 4 Giusca S, Schueler M, Willersinn E, Korosoglou G. Successful endovascular treatment of acute thromboembolic upper limb ischemia in a patient with atrial fibrillation. Int J Angiol 2019; 28 (04) 267-269
• 5 Seiffge DJ, De Marchis GM, Koga M. et al; RAF, RAF-DOAC, CROMIS-2, SAMURAI, NOACISP, Erlangen, and Verona registry collaborators. Ischemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. Ann Neurol 2020; 87 (05) 677-687
• 6 Senoo K, Lip GYH, Lane DA, Büller HR, Kotecha D. Residual risk of stroke and death in anticoagulated patients according to the type of atrial fibrillation: AMADEUS trial. Stroke 2015; 46 (09) 2523-2528
• 7 Falluji N, Mukherjee D. Critical and acute limb ischemia: an overview. Angiology 2014; 65 (02) 137-146
• 8 Noto T, Anzai H, Nemoto N. et al. Acute limb ischemia due to severe heparin-included thrombocytopenia with thrombosis during puerperium. J Cardiol Cases 2022; 27 (02) 56-59
• 9 Hess CN, Debus ES, Nehler MR. et al. Reduction in acute limb ischemia with rivaroxaban versus placebo in peripheral artery disease after lower extremity revascularization: insights from Voyager Pad. Circulation 2021; 144 (23) 1831-1841