Innominate artery saddle embolus: A pitfall for retrograde brachial embolectomy

Abstract

Embolic occlusion represents a frequent cause o f acute upper extremity ischemia. L2 Most upper extremity emboli are o f cardiac origin 1-s and typically produce acute arterial occlusion at or distal to the brachial artery. 1,3-6 Clinical history and physical examination adequately identify the approximate site o f occlusion 4-7 in most patients so that retrograde brachial artery balloon catheter embolectomy without preoperative angiography has become the current therapeutic standard. This article details our experience with the evaluation and treatment o f acute upper extremity occlusion resulting from what we believe to be the first reported case o f innominate saddle embolus. In particular, we describe the potential morbidity for retrograde e m b o l e c t o m y in this setting and the technical considerations for successful treatment o f this unc o m m o n clinical problem. CASE REPORTA 78-year-old woman had a 2-hour history of right arm pain, paralysis, and associated paresthesia. She had no significant medical history and no history of trauma. Her physical examination was notable for a regular cardiac rhythm, bilateral carotid bruits, absent right brachial, radial, and ulnar pulses, and the presence of a right axillary arterial signal by Doppler scanning. In addition, the patient had decreased sensation and decreased motor function of her right hand but no evidence of microemboli. The patient was presumed to have an upper extremity arterial embolus and within 3 hours underwent brachial artery

Acute Symptomatic Free-Floating Thrombus in the Innominate Artery, a Case Series

“…Acute IA thromboembolism has been described as secondary to cardiac embolism, 5,6 paradoxical embolism, 7,8 or even as secondary to arterial thoracic outlet syndrome. 9…”

“…In addition, when a distant embolectomy is performed, the right carotid and vertebral artery must be controlled to avoid cerebral embolization. 5…”

“…Acute IA thromboembolism has been described as secondary to cardiac embolism, 5,6 paradoxical embolism, 7,8 or even as secondary to arterial thoracic outlet syndrome. 9 Symptomatic acute in situ thrombosis of the supraaortic vessels with a free-floating thrombus may result in dislodgement and embolism of the thrombus, leading to anterior or posterior cerebral infarction (due to involvement of the right carotid or vertebral circulation, respectively) or upper extremity ischemia, with the potential risk of total or partial limb loss.…”

“…In addition, when a distant embolectomy is performed, the right carotid and vertebral artery must be controlled to avoid cerebral embolization. 5 Finally, it may leave the diseased plaque in situ, with the consequent risk of new thrombotic episodes.…”

Carotid–carotid crossover bypass after mechanical thrombectomy for internal carotid artery occlusion due to plaque from stenosed innominate artery

“…A previous report stated that the treatment of an IA saddle embolus must be performed with great care because of distal embolism. [ 6 ]…”