Acute upper limb ischemia complicating an inferior stemi of undetermined onset

Abstract Background Acute upper limb ischemia is an uncommon but potentially limb-threatening complication of ST-elevation myocardial infarction (STEMI). The prothrombotic state associated with acute coronary thrombosis, endothelial injury, and systemic inflammation may predispose to peripheral arterial embolization or in-situ thrombosis, even in the absence of overt cardiac thrombus. Case Illustration A 45-year-old woman presented with chest pain of undetermined onset. Electrocardiography demonstrated complete atrioventricular block, rate 32 bpm, and inferior ST-segment elevation, consistent with inferior STEMI. She underwent PPCI with temporary pacemaker insertion via femoral access. Coronary angiography revealed two-vessel disease with a thrombotic culprit lesion in the distal RCA, treated with a drug-eluting stent (Promus Premier 2.25 × 32 mm, 11–14 atm), achieving TIMI III flow. Post-procedurally, she developed left arm pain over the brachium, coldness from the cubital region to the hand, and variable oxygen saturation (51%-86%). Duplex ultrasonography demonstrated preserved proximal flow but thrombotic occlusion of the distal brachial, radial, and ulnar arteries. Transthoracic echocardiography revealed inferior wall hypokinesia, preserved LVEF (58.8%), and reduced RV systolic function (TAPSE 10 mm. Emergent surgical thrombectomy using a 4F Fogarty catheter evacuated three thrombi (15 cm thrombus from the ulnar artery, 5 cm thrombus from the radial artery, and 12 cm thrombus from the brachial artery) and restored distal perfusion. Oxygen saturation recovered to above 98% in all fingers. Conclusion Rapid diagnosis of the limb-threatening condition and coordinated multidisciplinary management are vital in optimizing patient outcomes. Prompt surgical embolectomy was limb-saving.Figure 1.(a) Coronary angiography showed 90% stenosis in the distal RCA; (b) Coronary angiography post stenting in the distal RCA; (c) Duplex ultrasonography demonstrated thrombus in the distal brachialis artery; (d) Duplex ultrasonography demonstrated thrombus in the ulnar artery.