Pulmonary embolism with aortic saddle embolism: a rare presentation
- Naveen Rajendra ,
- Radhakrishnan Raju ,
- Pranay Pawar and
- Jithin Sebastian
- Department of Vascular Surgery, Sri Ramachandra Medical College and Research Institute, Chennai, India
- Correspondence to Dr Naveen Rajendra; naveenrajendra@gmail.com
Abstract
We present an uncommon case report of simultaneous pulmonary embolism and aortic saddle embolism. This patient had risk factors for thromboembolic events that included recent surgery for tibia fracture and immobilisation. She underwent emergency bilateral pulmonary artery catheter-directed thrombolysis, followed by bilateral transfemoral embolectomy. The potential benefit of thrombolysis was weighed against the risk of haemorrhage during the surgery after thrombolysis. Treatment guidelines are not well established for such a condition. This case report illustrates our experience and challenges faced in treating this condition.
Background
Venous thromboembolism (VTE) manifests as deep venous thrombosis (DVT) and pulmonary embolism (PE), which is a major health and financial burden. Acute limb ischaemia results from sudden deterioration in the arterial supply, which if not treated urgently leads to limb loss and loss of life. When both the conditions present together, it becomes more complicated. Treatment guidelines are not set for such cases due to its rarity.
Case presentation
A 45-year-old woman presented to the emergency department with a 6-hour history of sudden-onset pain, paraesthesia, reduced movements of bilateral lower limbs, breathlessness and palpitations. Recently, she had a knee-spanning external fixator placed for right proximal tibia fracture after a road traffic accident.
On examination, her pulse rate was 112/minute, blood pressure was 94/68 mm Hg, respiratory rate was 30/minute and oxygen saturation at room air was 74%. Her both legs and feet were cold, tender and insensate to touch. Pulses were absent in both lower limbs. On Doppler examination, there was no flow in the right lower limb arteries; left anterior tibial artery flow was 30 mm Hg and rest of the left lower limb arteries showed no flow.
After relavent investigations (discussed below), cardiologists’ opinion was taken and the plan regarding the most appropriate treatment modality was discussed.
During this process, despite the supplement of oxygen, the blood oxygen saturation further decreased, and the patient became drowsy and disoriented. The patient was intubated and transferred to the operating room for surgery (described below).
After the intervention, the oxygen saturation readings showed an upward trend, reaching a normal value within 60 min. Two-dimensional echo was performed immediately after the operation which showed significant improvent in heart function, the pulmonary artery pressure was reduced to 48 mm Hg, the right ventricular contractility was better, and the ejection fraction was 54%.
Investigations
Total leucocyte count was elevated to 18.2 x109/L; D-dimer level was elevated to 18.06 μg/mL, the ECG showed sinus tachycardia and S1Q3T3 suggestive of PE. There was no evidence of arrhythmia.
Two-dimensional echocardiogram showed dilation of the right atrium and ventricle, poor right ventricular contraction, pulmonary artery pressure of 68 mm Hg, no clots and ejection fraction of 48%.
Bilateral lower limb venous duplex showed no signs of deep vein thrombosis.
CT peripheral angiogram and CT pulmonary angiogram showed embolic occlusion at the aortic bifurcation extending into the common iliac arteries (figure 1), non enhancing hypodense filling defect in bilateral pulmonary arteries extending into its lobar and segmental branches (figure 2), communited fracture of right proximal tibia with metallic external fixation prosthesis, altered attenuation in lower superficial femoral vein, deep femoral vein, popliteal vein and calf veins on the right side suggestive of deep vein thrombosis. Patent foramen ovale could not be ruled out as transoesophageal echocardiography was not done.
CT peripheral angiogram showing emboli at the aortic bifurcation and in both iliac arteries.
CT pulmonary angiogram showing embolism.
Diagnosis
Massive PE with Rutherford class 2b acute limb ischaemia due to aortic saddle embolism.
Treatment
Catheter-directed thrombolysis (CDT) of PE and bilateral transfemoral embolectomy.
Procedure: right internal jugular vein access was taken under ultrasound guidance. 0.035 guide wire and Judkins right catheter was used to reach the pulmonary trunk. Ten mg tenecteplase was injected into each pulmonary artery. After 30 min, bilateral transfemoral embolectomy was done using Fogarty 5F and 4F catheter. The patient also underwent fasciotomy of the leg compartments.
Outcome and follow-up
She had a remarkable postoperative recovery. She was closely monitored in the intensive care unit for 24 hours to check for signs of respiratory distress, compartment syndrome, worsening of limb ischaemia. Immediately after surgery, parenteral anticoagulation with enoxaparin was started. Tablet nicoumalone was started on the 5th day and the patient was discharged on day 8.
The patient was readmitted on postoperative day 60 for the external fixator removal and work up of thrombophillia. Nicoumalone was stopped and parenteral anticoagulation was restarted. Thrombophilia workup showed normal values of homocysteine (12.28), protein C (125.8), protein S (90.0), antinuclear antibodies (negative), anticardiolipin antibodies (IgG 2.1 and IgM <2.0), beta 2 glyco protein (IgG 0.49 and IgM 1.11) and factor 5 Leiden mutation (negative). External fixator was removed and patient was mobilised normally. The patient was restarted on nicoumalone, discharged and was asked to come for follow-up once in 15 days with prothrombin time and international normalized ratio test for titration of dose of nicoumalone. The fasciotomy wounds healed by secondary intention.
Discussion
VTE is a major health and financial burden that affects the community.1 This condition is the third most common vascular disorder in Caucasian populations after myocardial infarction and stroke.2 VTE presents as DVT and PE. Wells score has well-established criteria for suspected DVT and PE.3 4 The Revised Geneva and Simplified Revised Geneva are other scoring systems for predicting PE.4 5 D-dimer levels can be used to support clinical diagnosis.6 Duplex ultrasonography and computed tomographic (CT) venography7 have been the imaging modalities used for diagnosing DVT. Pulmonary CT angiography has replaced ventilation perfusion scintigraphy of the lung and conventional pulmonary angiography4 8 for detection of PE.
In order to prevent VTE or its recurrence, pharmacological and/or mechanical approaches are administered.8–10 To treat VTE, various treatment modalities in the form of anticoagulation, thrombolysis and vena cava filter have been employed.
Acute limb ischaemia is the result of a sudden deterioration in the arterial supply. Emboli can occlude any artery, but in the legs, the common femoral and popliteal arteries are commonly obstructed. Only large emboli, so called saddle emboli, occlude the normal aortic bifurcation. Embolic ischaemia is usually catastrophic because it often occurs in otherwise normal arteries, without any established collaterals. Investigations like duplex ultrasound, CT angiography, MR angiography and echocardiogram are valuable to confirm the diagnosis and to plan appropriate treatment. However, when the limb is critical, there is no time for investigation and the patient has to be taken up for surgery.
Paradoxical embolus is a condition that combines arterial embolus and DVT in the presence of an atrial or ventricular septal defect.11 12 Venous duplex is used to diagnose DVT, which is by far the most common source. CT angiography is done to identify the embolic arterial occlusion. Echocardiography is done to diagnose septal defects.
Paradoxical embolus patients mostly require surgical intervention. In addition, all patients receiving treatment should be evaluated for Patent foramen ovale closure.13 14 All patients with paradoxical embolism should be treated with long-term anticoagulation therapy unless contraindicated.
Our patient had features of PE and aortic saddle embolism, which was clinically established and confirmed by radiological assessment. Paradoxical embolism was not ruled out and further evaluation like transoesophageal echocardiography was required. The course of the condition was acute and adverse, needing urgent intervention. CDT for PE was preferred over systemic thrombolysis because of its more specific site of delivery of the drug and also the reduced dose requirement. These benefits of CDT were thought to reduce the risk of haemorrhage during embolectomy.
Patient’s perspective
I thank all the doctors who were involved in treating my condition. I would not have survived without their timely intervention and care.
Learning points
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Pulmonary embolism is a potentially life-threatening condition, presenting along with aortic saddle embolism makes it more fatal.
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Treatment guidelines have not been well established for such a condition due to its rarity.
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Appropriate decision making and rapid treatment plays a crucial role in saving lives.
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This case report provides insights into treatment options for this kind of rare case.
Ethics statements
Footnotes
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Contributors NR: the author of the article who also worked up the case, assisted the surgery and took care of the post operative course. RR: is the primary surgeon of the case and also the co author, provided his guidance for writing up this article. PP: played a part in the work up and was the assistant for the surgery, also provided his inputs. JJS: was the assistant for the surgery, provided his inputs during management.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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