Atypical Presentation of Acute Limb Ischemia in a Hypertensive Emergency With Nstemi and Pulmonary Edema

A 36-year-old man with known type 2 diabetes mellitus and a history of chronic smoking was seen in the Emergency Department with symptoms of giddiness, diaphoresis, headache, numbness in the right lower limb, and acute dyspnoea. The initial presentation was that of hypertensive emergency and pulmonary oedema. ECG abnormalities and cardiac enzyme levels were suggestive of non-ST-elevation myocardial infarction (NSTEMI). Interestingly, clinical assessment showed absent distal pulses and sensory loss in the right lower limb. Although neurological deficits were suggestive of a cerebrovascular accident (CVA), peripheral angiography established acute limb ischemia (ALI) by virtue of extensive thrombotic occlusion of the right lower limb arterial system. Echocardiography was positive for regional wall motion abnormalities but no intracardiac thrombus. The patient was taken for emergent right transfemoral embolectomy and fasciotomy, and later was started on anticoagulation and dual antiplatelet therapy. Postoperatively, the distal pulses were restored, and the patient had an uneventful recovery. This case emphasizes the need for elevated clinical suspicion in patients with unusual limb symptoms and cardiovascular instability. Early vascular imaging and surgical repair were important in limb salvage and stabilization.