Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

Abstract

Left ventricular thrombus (LVT) is a well-known complication of myocardial infarction (MI) leading to significant morbidity and mortality. LVT can also lead to systemic thromboembolic events causing threatening limb ischemia. We report a rare case of critical bilateral limb ischemia that resulted from peripheral embolization of LVT post MI, which was managed successfully by emergent surgical intervention and anticoagulation. A 74-year-old male with a medical history of hypertension, diabetes, hyperlipidemia and coronary artery disease status post stenting of the left anterior descending and left circumflex arteries presented to the emergency department with typical chest pain and progressive shortness of breath. Cardiac troponin levels on admission were 35 ng/mL of blood. The patient subsequently underwent emergent cardiac catheterization which revealed significant triple vessel disease, and was referred for coronary artery bypass grafting (CABG) surgery. Transthoracic and transesophageal echocardiograms revealed the presence of an apical aneurysm with chronic organized mobile thrombus at the apex. Post CABG, the patient complained of excruciating right leg pain. Computed tomography (CT) angiogram of the abdominal aorta and lower extremities revealed a large embolus at the aortic bifurcation occluding the right and nearly occluding the left common iliac arteries and thrombus in the right popliteal artery. He underwent emergent vascular surgery with resolution of his symptoms and remained without further complications. The incidence of LVT remains high in post-MI patients, and complications of LVT are known to include thromboembolic events. Peripheral embolization of acute or chronic LVT leading to bilateral distal embolization and critical limb ischemia remains a rare occurrence. This case report aims to aid clinicians to recognize and promptly manage LVT and related arterial thromboembolic events with anticoagulation and emergent surgical intervention if limb ischemia develops.

Keywords: Ischemia; Myocardial infarction; Peripheral embolization; Thromboembolism; Ventricular thrombus.

Figure 1

(a) Transthoracic echocardiogram (TTE) done pre-CABG surgery showing a mobile left ventricular (LV) apical thrombus associated with an LV aneurysm. (b) TTE done post-CABG surgery and anticoagulation treatment showing decreased size of LV apical thrombus.

Figure 2

(a) Computed tomography (CT) scan of the abdomen showing a large embolus at the aortic bifurcation. (b) CT scan of the abdomen showing occlusion of the right common iliac and near occlusion of the left common iliac artery.

Figure 3

Computed tomography (CT) angiogram of the abdominal aorta and lower extremities showing right common iliac and right popliteal artery occlusion.