Our case was a 69-year-old male patient with multiple underlying medical conditions, including atrial fibrillation on long-term edoxaban therapy, concurrent right hypopharyngeal cancer with lung metastasis receiving chemotherapy, chronic kidney disease, and coronary artery disease. The patient was sent to our emergency department with sudden onset left arm and right lower limb pain, paresthesia, and persistent cold sensation. He had recently undergone right upper lobe lung wedge resection and had discontinued edoxaban therapy for 2 weeks.

Physical examination revealed a pale left upper limb and right lower limb with weak radial and dorsalis pedis pulsation. Laboratory tests indicated elevated levels of C-reactive protein at 43 mg/L and D-dimer at 9.04 mg/L. Electrocardiography demonstrate atrial fibrillation. Emergent left upper limb computed tomography angiography revealed thrombosis below the left brachial artery, confirming acute limb ischemia (Figure 1). Percutaneous angioplasty was immediately performed. Initial angiography revealed extensive thrombosis at the left brachial, ulnar, and radial arteries (Figure 2A). A similar thrombotic picture was observed in the right common iliac artery, right external and internal iliac arteries, and right femoral artery (Figure 3A). Fortunately, the bilateral renal arteries and superior mesenteric artery remained patent. After discussing with patient and family, Rotarex device was used for thrombosis over multiple arterial territories. After several times of thrombus suction, we successfully treated the patient with Rotarex thrombectomy over left brachial artery, and further performed angioplasty over ulnar, and radial arteries. Similar procedures were performed over the right external iliac and common femoral arteries. Fountain catheter were then placed in the left axillary artery and right common iliac artery for further Catheter-Directed Thrombolysis (CDT). Second angiography after 1-day CDT confirmed patent left brachial, ulnar arteries (Figure 2B), and right external iliac and common femoral arteries (Figure 3B). A follow-up brachial-ankle index assessment conducted two days later showed normal results, confirming the restoration of blood flow. The patient was discharged one week later, receiving long-term anticoagulation therapy with dabigatran without notable complications.