Multisystem Thromboembolic Shower in the Intensive Care Unit: Acute Limb Ischemia and Mesenteric Embolism

Acute limb ischemia is a catastrophic vascular emergency that can easily be obscured by the physiological noise of septic shock and mechanical ventilation within the intensive care unit.

A 75-year-old Caucasian woman presented to the emergency department and was subsequently admitted to the intensive care unit with acute hypoxic respiratory failure and severe septic shock secondary to a primary lobar bacterial pneumonia. She was obtunded, tachycardic, and hypotensive upon arrival. She experienced a transient 4-hour paroxysm of new-onset atrial fibrillation. Targeted physical examination revealed a profoundly cold right lower extremity with absent peripheral pulses. Emergent computed tomography angiography revealed a complex, multisystem macrovascular catastrophe: an acute superior mesenteric artery occlusion alongside a 15-mm right common iliac artery thrombus causing near-subtotal occlusion. Prompt systemic anticoagulation and surgical thrombectomy successfully preserved bowel viability and avoided a major lower limb amputation.

Widespread multibed embolic showers require high clinical suspicion when brief tachyarrhythmias interact with the hypercoagulable cascade of systemic sepsis.

Systematic peripheral vascular assessments are vital in complex sepsis presentations to prevent devastating diagnostic delays.