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Case Reports
. 2019 Aug 28;12(8):e230024.
doi: 10.1136/bcr-2019-230024.

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

Enrico Mancuso  1 , Andrew Philip Winterbottom  2 , Jonathan R Boyle  3 , Diane R Hildebrand  3
Affiliations
Case Reports

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

Enrico Mancuso et al. BMJ Case Rep. .

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.

Keywords: adult intensive care; pulmonary embolism; radiology; stroke; vascular surgery.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
CT pulmonary angiogram on presentation, prethrombolysis. This CT scan was performed at the spoke hospital on arrival into the emergency department to rule out pulmonary embolisms which represented the most likely diagnosis. (A) Bilateral pulmonary embolisms. (B) Saddle embolus sitting in the aortic arch. (C) Saddle embolus involving both succlavian artery and aortic arch. (D) Involvement of brachiocephalic trunk and full patency of carotid arteries. (E) Patent right carotid artery.
Figure 2
Figure 2
Post-thrombolysis CT angiogram. A repeated CT scan was performed in order to review the evolution of the embolic event and plan surgical treatment. (A) Resolving pulmonary embolisms. (B) Aortic arch free of embolus. (C) Proximal subclavian arteries and aortic arch free of embolus. (D) Embolic occlusion of the right carotid artery. (E) Embolic occlusion of the right carotid artery.
Figure 3
Figure 3
CT head showing right middle cerebral artery (MCA) embolic infarct.
See this image and copyright information in PMC

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