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.

Role of POCUS in Assessing an Acute Aortic Thrombus

“…Previous literature suggests multiple potential causes of aortic thrombi, including intrinsic aortic pathology such as dissection or abdominal aortic aneurysm (AAA), or extrinsic causes such as hypercoagulability 1 , 2 , 3 , 4 , 5 . Both the aortic thrombus and associated intrinsic aortic pathology can be visualized with POCUS.…”

“…Without anticoagulation, she was at high risk for both development and propagation of thrombus. While atrial fibrillation offers a potential etiology, especially since no alternate etiology was found, this is an unusual cause of proximal aortic thrombus as thrombi from atrial fibrillation often travel more distally due to its size and the aorta’s high velocity flow 5 .…”

Acute Brachial Artery Occlusion on Point-of-Care Ultrasound in the Emergency Department: A Case Report

“…A ventricular thrombus can form in vivo, or secondary to recent myocardial infarction, and is often the source of peripheral arterial occlusions. 10 In patients presenting to the ED with arterial occlusion, it may be beneficial to perform a POCUS echocardiogram to evaluate for a thrombotic source.…”

Recurrent axillary artery thrombosis due to myocardial infarction

“…Their patient presented with bilateral lower limb ischaemia after coronary artery bypass grafting following a recent myocardial infarction. 5 LV thrombus can occur…”