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Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 251-252

Perioperative management of a double hit - Acute limb ischemia in a patient with acute myocardial infarction

Consultant Vascular and Endovascular Surgeon, Kauvery Hospitals, Salem, Tamil Nadu, India

Date of Submission01-Feb-2022
Date of Acceptance09-May-2022
Date of Web Publication21-Aug-2022

Correspondence Address:
Karthikeyan Sivagnanam
Consultant Vascular and Endovascular Surgeon, Kauvery Hospitals, Salem, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_10_22

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This case report highlights our experience in managing two cases of acute lower limb ischemia with simultaneous acute coronary events. One patient was detected with acute ST-elevation myocardial infarction while being evaluated for acute lower limb ischemia and another patient had NSTEMI with acute left ventricular failure and delayed presentation of acute lower limb ischemia. Both had good outcomes.

Keywords: Acute limb ischemia, femoral embolectomy, STEMI with embolic limb ischemia

How to cite this article:
Sivagnanam K. Perioperative management of a double hit - Acute limb ischemia in a patient with acute myocardial infarction. Indian J Vasc Endovasc Surg 2022;9:251-2

How to cite this URL:
Sivagnanam K. Perioperative management of a double hit - Acute limb ischemia in a patient with acute myocardial infarction. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Sep 25];9:251-2. Available from:

  Introduction Top

Acute myocardial infarction can be associated with systemic thromboembolism secondary to left ventricle thrombus. The incidence varies from 15% in patients with ST-elevation myocardial infarction (MI) to 25% in patients with large anterior MI.[1] Patients with pre-existing peripheral arterial disease can also present with similar symptoms of limb ischemia probably due to a low output state when they develop acute left ventricular (LV) failure.

A 48-year-old man, a chronic smoker, presented with sudden onset of painful right leg for 8 h duration with the inability to move his toes. In view of acute lower limb ischemia, the preoperative evaluation showed he had non-ST elevation MI on electrocardiography. He denied any symptoms of chest pain. Computed tomography (CT) angiogram revealed right superficial femoral artery (SFA) occlusion with good outflow distally. He underwent emergency transfemoral embolectomy and fasciotomy for the leg under local anesthesia supported with mild sedation. In view of acute NSTEMI, to avoid exaggerated reperfusion syndrome, he was monitored in the intensive care unit (ICU), strict fluid resuscitation measures followed and his MAP was titrated between 70 and 80 mm Hg. He developed mild acute kidney injury in the immediate postoperative period. However, he made a gradual recovery and later digitalized due to poor ejection fraction and anticoagulated. He was on follow-up for 6 months and recovered completely from the surgery.

The second case was a 60-year Type 2 obese diabetic male who presented with a recent onset painful right leg associated with rapidly worsening numbness over 10 days. He also had dyspnea on exertion for 3 days which forced him to use a wheelchair while presenting to the outpatient department. On examination, he had subacute right lower limb ischemia and acute LV failure. He was optimized in ICU with diuretic agents, anticoagulation, dobutamine infusion to improve cardiac contractility. CT angiogram showed diffuse calcifications in both lower limbs with right SFA occlusion. He had diffusely diseased vessels in both lower limbs and in the aorta. In view of acute LV failure, he underwent right transfemoral thrombectomy to remove the clots. The procedure was successful in removing the fresh thrombus, and his leg perfusion improved though there were no palpable pedal pulses. The embolectomy opened the peroneal artery, and perfusion was improved. He recovered from the numbness in his legs and his walking capacity improved slowly. He was discharged on digoxin, anticoagulation, and antiplatelets and followed up eventually by the cardiologist.

  Discussion Top

Both the cases illustrated had lower limb ischemia with the acute coronary event, which were managed simultaneously and had a successful outcome. This was possible due to a multi-disciplinary team of vascular specialists, intensivists, anesthesiologists, and cardiologists. The double hit ischemia has high events of mortality and limb loss.[1] Despite the advances in treatment, arterial revascularization following acute lower limb ischemia is associated with significant morbidity and mortality.[2] Such incidences of combined events are rare in published literature. Having come across two such cases with fortunate outcomes was a reason behind publishing them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL Jr., Bhatt DL, McEvoy JW. Left ventricular thrombus after acute myocardial infarction: Screening, prevention, and treatment. JAMA Cardiol 2018;3:642-9.  Back to cited text no. 1
Kempe K, Starr B, Stafford JM, Islam A, Mooney A, Lagergren E, et al. Results of surgical management of acute thromboembolic lower extremity ischemia. J Vasc Surg 2014;60:702-7.  Back to cited text no. 2


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