Management and clinical outcome of concomitant pulmonary embolism and paradoxical saddle aortic arch embolism

Abstract

A 65-year-old man presented in a peri-arrest situation after collapse, he was found hypoxic with ischaemic arms. CT imaging showed massive bilateral pulmonary embolisms (PEs) and an aortic arch embolus extending from brachiocephalic trunk to left subclavian artery. Following intravenous thrombolysis, repeat imaging revealed that the aortic embolus had migrated distally into both axillary arteries and had occluded the right carotid from origin to skull base. Bilateral upper limb embolectomies were carried out from the brachial arteries together with forearm fasciotomies. Left hemianopia related to a right middle cerebral artery territory infarct was managed conservatively; forearm fasciotomy wounds were primarily closed and the patient was discharged on lifelong anticoagulation. A transoesophageal echocardiogram revealed a patent foramen ovale. This case demonstrates a very unusual presentation of concomitant PE and paradoxical saddle aortic arch embolism. A multidisciplinary approach has resulted in an excellent clinical outcome for this complex patient.

Pseudo-high risk acute pulmonary embolism resulting from a large saddle aortic paradoxical embolus with subclavian artery occlusion

“…ischemic stroke or peripheral embolization. [4] Despite finding only one report of successful aortic arch thrombolectomy with simultaneous pulmonary artery embolectomy, we think that surgical management should be preferred. [5] Our case demonstrates the need for awareness of the risk of systemic embolism in patients with APE and RV overload.…”