Warfarin-Induced Skin Necrosis Mimicking as Acute Limb Ischemia: a Surgical Conundrum

"Warfarin-induced skin necrosis” is a rare complication, with a reported incidence of 0.01–0.1%. Initiation of warfarin therapy causes a transient procoagulant state which must be balanced with heparin therapy, else the procoagulant state leads to microthrombi formation which can cause skin necrosis, amongst other complications. We present one such case of a 63-year-old gentleman, who had presented to a hospital with right lower limb claudication and was offered anticoagulation with oral warfarin which led to blackish discoloration of the right lower limb. It was thought as acute limb ischemia (Rutherford class III), and he was offered a trans-tibial amputation. He, on being evaluated at this vascular surgery center, was diagnosed as “warfarin-induced skin necrosis,” with right femoro-popliteal artery segment occlusion. He was managed with an autologous vein bypass, skin debridement, and a soft tissue coverage using a split thickness skin graft. This deceptive yet well-established condition of warfarin therapy carries a high degree of morbidity and should be promptly addressed to minimize the associated morbidity.