This document presents a case study of an 8-year-old male patient who presented with acute ischemia in his left upper limb. Further examination revealed a large mobile mass in both the patient's left and right atria, which was protruding through the mitral and tricuspid valves. The patient underwent an emergency thrombembolectomy of the left upper limb arteries to treat the acute ischemia. Additional imaging showed an atrial thrombus lodged in a patent foramen ovale. The patient later underwent open heart surgery to remove the thrombus and close the foramen ovale. The surgical treatment was staged with the initial focus on resolving the acute limb ischemia, followed by cardiac intervention to address the source of embolism

1. Acute embolic peripheral ischemia originating from biatrial thrombus –
case presentation
A. Parnia (1), Mihaela Salagean(1), C. Voica (2), M. Robu(2), Anca Lupa(3), Sorin Baila (1)
(1) IUBCV Prof Dr CC Iliescu, Chirurgie Vasculara, Bucuresti, Romania; (2) IUBCV Prof Dr CC Iliescu, Chirurgie
Cardiovasculara 1, Bucuresti, Romania; (3) IUBCV Prof Dr CC Iliescu, ATI 1, Bucuresti, Romania
Introduction: Peripheral arterial embolism is one the most common causes of acute limb ischemia in elder patients.
Most of the cases the embolus is a thrombembolus of cardiac origin. In cases of persistence of a left-right
communication a paradoxical embolism may occur. Identification and control of emboli source is crucial in treatment
and prevention of further embolic events.
Case presentation: We present a case of a 8y y.o. male patient, presented at the ER with acute upper left limb ischemia.
Patient’s past medical history: surgery for colonic cancer (10 years before), varicose veins of the lower limbs, type II
diabetes mellitus, one episode of right lower limb swelling.
Clinical findings: BP=110/65mmHg, HR=100b/min, SpO2=95%, rhythmic cardiac sounds, no cardiac murmurs, no
pulmonary stasis, calf edema (right>left), varicose veins, mottled cold skin in the left upper arm, absence of axilary,
brachial, radial and ulnar pulses, partial motor and sensitive impairment.
Biologic findings: NTproBNP = 966 pg/mL; D-dimer = 4.88 µg/mL; CK/CK-MB=73/17 /L, TnI=0.02 ng/mL, blood
glucose=140 mg/dL; otherwise – normal values.
Thrombemboli extracted from
the left upper limb arterial axis
Continuous Doppler showed absence of arterial signal and presence of
venous signal in the distal left upper limb. (stage II B peripheral acute
ischemia- Rutherford classification)
Cardiac transthoracic echocardiography was performed in the ER,
revealing good sistolic function of LV, no significant valvular disease and a
large mobile mass in the left and right atrium, prolapsing through the
mitral and tricuspid valves.
Emergency surgical intervention was performed in order to treat acute
left upper limb ischemia. Fogarty catether open thrombembolectomy of
the axilo-brachio-radio-ulnary arterial axis was performed by brachial
bifurcation approach.
Postoperative course was uneventful, with total recovery of vascular and
functional status of the left upper limb.
Further imaging investigations were
performed. Transthoracic and
transesophageal ecocardiography, revealed a
very mobile atrial thrombus, inclavated in an
patent foramen ovale.
Coronarography was perfomed to exclude
cardiac ischemic disease (no hemdinamically
significant coronary artery lession)
After comlpeting surgical preparation protocol,
the patient underwent open heart surgery
with foramen ovale closure and atrial
thrombus extraction.
No complications occurred. Postoperative
course was uneventful, patient being
discharged from hospital in the 10th day.
Ambulatory postoperative treatment consisted
in VKA, ASA, statin, antihipertinsive drugs and
oral antidiabetics .
Intraoperative view of the the atrial thrombus
beig pulled through the patent foramen ovale
Atrial thrombus
Discussion: This is a particular case of a patient with inclavated
thrombus in a patent foramen ovale. The main clinical aspect
was that of acute peripheral ischemia. The surgical treatment
was staged- emergency intervention for acute peripheral
ischemia and elective cardiac intervention for thrombus
removal and foramen ovale closure.