E-CHALLENGES & CLINICAL DECISIONS

Feroze Mahmood, MD
Madhav Swaminathan, MD
Section Editors

Acute Limb Ischemia and Transesophageal Echocardiography: Making a Case

Mauricio Garcia-Jacques, MD,* Mario Montealegre-Gallegos, MD,* and Robina Matyal, MD*

A 64-YEAR-OLD FEMALE presented to an outside facility

with acute onset of left upper extremity pain with
associated pallor and weakness. On clinical examination, an
(Video clip 1). Complex immobile atheroma/calcications
were also observed in the entire descending aorta. Of note,
as opposed to the CT angiography results, intraoperative
absence of radial and ulnar pulses was noted, and a heparin TEE identied 2 mobile echo densities of considerably
infusion immadiately was started. Within 30 minutes of the large size.
initiation of heparin, there was improvement in her symptoms
without restoration of palpable pulses, and she was transferred INTRAOPERATIVE COURSE
urgently to the authors hospital. The patient had a remote
Due to the nature of her problems, the authors pursued a
history of an acute episode of lower limb ischemia. She had
multi-disciplinary intraoperative approach. The cardiac surgical
been non-compliant with her medications and reported dis-
team was consulted emergently for their opinion regarding the
continuing her daily aspirin 3 months prior to the current
management of the aortic thrombus. According to the cardiac
episode of upper extremity ischemia. On a transthoracic
surgical opinion, the position of the thrombus precluded it from
echocardiogram performed during the workup at the authors
adequate surgical resection without deep hypothermic circu-
hospital, she had normal biventricular systolic function and an
latory arrest. They suggested that the risk-benet ratio in this
enlarged left atrium. Due to the suboptimal nature of the
particular case favored long-term anticoagulation with close
transthoracic echocardiography study, an intracardiac shunt
followup to assess for recurrence of embolism.
could not be excluded. A duplex scan of the left upper
extremity demonstrated a mid-ulnar and distal radial artery
non-occlusive thrombus with diminished ow distal to the ECHOCARDIOGRAPHIC CHALLENGES
obstruction. Computed tomographic (CT) thoracic angiogram Should intraoperative TEE be performed routinely in cases
revealed a calcied ovoid lling defect of 1 cm  0.7 cm of acute upper and lower limb ischemic episodes to exclude a
adherent to the inferior aortic wall at the level of the left cardiac source of thrombus?
subclavian artery ostium.
Due to continued absence of distal pulses despite heparin CLINICAL CHALLENGES
infusion, an emergent ulnar artery thrombectomy was per-
formed under general anesthesia. To denitively exclude the What should the clinical course of management be in cases
presence of an intracardiac shunt or thrombi, an intraoper- with unanticipated ndings on the TEE examination?
ative transesophageal echocardiogram (TEE) was performed
after induction of anesthesia. In this case, TEE did not reveal
any intracardiac shunts or thrombi. Two mobile echogenic
densities were found on the posterior wall of the distal
aortic arch attached to a focal calcication on the aortic
wall. These mobile echo densities were measured to
be 2 cm  1 cm and 0.6 cm  0.5 cm respectively (Fig 1)

From the *Department of Anesthesia, Critical Care, and Pain

Medicine, Beth Israel Deaconess Medical Center, Harvard Medical
School, Boston, MA; and Department of Anesthesia, Hospital Mexico
C.C.S.S., Universidad de Costa Rica, San Jose, Costa Rica.
Address reprint requests to Mario Montealegre-Gallegos, MD,
Harvard Medical School, One Deaconess Road, CC 470, Boston, MA
02215. E-mail: mmonteal@bidmc.harvard.edu
2014 Elsevier Inc. All rights reserved.
1053-0770/2602-0033$36.00/0
http://dx.doi.org/10.1053/j.jvca.2014.03.006 Fig 1. Mobile echogenic density on the posterior wall of the distal
Key words: aortic thrombus, arterial embolism aortic arch.

1164 Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 11641165
GARCIA-JACQUES ET AL
Considering the risk of embolism, should the clinicians involved
in this patients care exercise therapeutic privilege and proceed
with additional procedures for which the patient not consented?
Do such intraoperative diagnoses and management deci-
sions based on unanticipated echocardiographic ndings fall
within the purview of basic intraoperative echocardiography?
CLINICAL COURSE
Consequently, after the embolectomy, the patient was main-
tained on intravenous heparin, which was transitioned to oral
coumadin, and was discharged uneventfully a few days later.
DISCUSSION
The unexpected presence of intracardiac and aortic densities
on TEE in these high-risk emergency vascular cases can alter
intraoperative surgical management. The utility of TEE as a
tool for evaluation and identication of the source of emboli
has been established in the past.13 The proper management of
these unexpected scenarios depends on the location of the
thrombus, the emergency nature of the procedure, and the
expected risk and benet evaluation. Most importantly, a
consensus is needed from the involved anesthesiologist and
REFERENCES
1. Amarenco P, Cohen A, Baudrimont M, et al: Transesophageal
echocardiographic detection of aortic arch disease in patients with
cerebral infarction. Stroke 23:1005-1009, 1992
2. Amarenco P, Cohen A, Tzourio C, et al: Atherosclerotic disease of
the aortic arch and the risk of ischemic stroke. N Engl J Med 331:
1474-1479, 1994
3. Russo C, Jin Z, Rundek T, et al: Atherosclerotic disease of the
proximal aorta and the risk of vascular events in a population-based
For further information and follow-up discussion of the E-Challenge, please go to:
(1) JCVA online web page for the video images at www.JCVAonline.com
(2) JCVA blog site for adding your comments or for viewing the other responses: http://JCVAblog.blogspot.com
1165
vascular and cardiac teams. In this particular case, a decision to
proceed with removal of the thrombus would have involved
deep hypothermic circulatory arrest with its associated compli-
cations. The surgical decision of conservative management was
within the same scope of acceptable practice as a decision to
operate would have been.
The authors group previously has published similar reports
of acute limb ischemia in which intraoperative TEE demon-
strated ndings that led to a major change in management.4 In
the aforementioned case, the size and location of the aortic
thrombi on TEE imaging were different from the preoperative
report and led to a therapeutic dilemma. This raises the
question of whether or not TEE should be performed routinely
in acute limb ischemia to exclude a cardiac cause and locate the
source of the thrombus, evaluate the potential for further
embolism, and assess the difculty involved in resecting the
thrombus.
APPENDIX A. SUPPLEMENTARY INFORMATION
Supplementary data associated with this article can be found
in the online version at doi:10.1053/j.jvca.2014.03.006.
cohort: The Aortic Plaques and Risk of Ischemic Stroke (APRIS) study.
Stroke 40:2313-2318, 2009
4. Matyal R, Wang A, Mahmood B, et al: A woman with a history of
stroke and a mass in the aorta. J Cardiothorac Vasc Anesth 27:
197-198, 2013