The importance of transesophageal echocardiography evaluation in a patient with acute limb ischaemia.

This a case of a patient with acute limb ischaemia in whom thorough transesophageal echocardiography (TEE) evaluation depicted a patent foramen ovale and allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta. We aim to illustrate the importance of performing TEE when systemic emboli are suspected and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected.

Case description

We present the case of a 55-year-old man, obese (body mass index 30.4 kg/m2), active smoker, with no past medical history. He was admitted because of an acute ischaemia of the right lower limb, for which he underwent urgent successful percutaneous femoral embolectomy. Transthoracic echocardiography showed hypermobile atrial septum, but no clear evidence of potential embolic sources. Since a thrombus with myxoid features was identified during embolectomy, the patient was referred for a transesophageal echocardiography to simultaneously exclude potential cardioembolic and aortic sources of emboli, as well as the presence of patent foramen ovale (PFO) as a cause of paradoxical embolism. Indeed, he had a thin and hypermobile atrial septum with a PFO (panel A, ) that was only detected after agitated saline injection associated with a Valsalva manoeuvre, with the passage of 5–25 microbubbles (Grade 2/4 shunt) and an atrial septum aneurysm, with an excursion of the fossa ovalis towards the right atrium of 11 mm (panel A, Supplementary material online, ). Ascending aorta was normal, but descending aorta depicted a hypermobile mass starting at 35 cm from the incisors, and ending at aortic arch (transversal area:1,76 cm2, length:7 cm) (panel B, ). An angio-computed tomography (CT) was immediately performed, which depicted an atheromatous calcified plaque in the terminal portion of the aortic arch, giving rise to the image suggestive of thrombus, and extending for about 6 cm to the medium third of the descending thoracic aorta (panel C, ). Owing to symptomatic embolization from an aortic thrombus of large dimensions, the patient was subjected to an urgent thoracic endovascular aortic repair to trap and cover the thrombus with an endograft to prevent further embolization, with an adequate final clinical result.[1] Syphilis, thrombophilia, and auto-immune disease were excluded, as well as malignancies through anamnesis, physical examination, and performance of thoraco–abdominal–pelvic CT. Aortic atherosclerotic disease and thrombus were considered the underlying aetiology and not the PFO.[2] After 16 days, he was discharged asymptomatic, with no signs of ischaemia and treated with oral anticoagulation with rivaroxaban 20 mg, atorvastatin 40 mg, and strict smoking cessation.[3] Ten months following the initial event, the patient developed left arm claudication and angio-CT showed left subclavian artery (LSA) occlusion. He underwent LSA angioplasty with stents, with resolution of arm claudication. At 2-year follow-up, he remained asymptomatic and complied with the prescribed medication.

Transesophageal echocardiography images: panel A: patent foramen oval with a tunnel width of 2.6 mm (arrow), LA, left atrium, RA, right atrium, S, septum; panel B: hypermobile mass starting at 35 cm from the incisors, showed in 2D transversal (B1) and longitudinal axis (B2). Angio-CT images: panel C: thoracic aorta atherosclerotic plaque (arrow).

Author contributions

M.C. had the idea of publishing this case and prepared the manuscript. A.B. prepared the multipaneled image and MQ prepared the 3D image. All the authors were present during transesophageal echocardiography evaluation, and all reviewed the case manuscript.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

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