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 absence of radial and ulnar pulses was noted, and a heparin infusion immadiately was started. Within 30 minutes of the initiation of heparin, there was improvement in her symptoms without restoration of palpable pulses, and she was transferred urgently to the authors’ hospital. The patient had a remote history of an acute episode of lower limb ischemia. She had been non-compliant with her medications and reported discontinuing her daily aspirin 3 months prior to the current episode of upper extremity ischemia. On a transthoracic echocardiogram performed during the workup at the authors’ hospital, she had normal biventricular systolic function and an enlarged left atrium. Due to the suboptimal nature of the transthoracic echocardiography study, an intracardiac shunt 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 flow distal to the obstruction. Computed tomographic (CT) thoracic angiogram revealed a calcified ovoid filling defect of 1 cm 0.7 cm adherent to the inferior aortic wall at the level of the left subclavian artery ostium. Due to continued absence of distal pulses despite heparin infusion, an emergent ulnar artery thrombectomy was performed under general anesthesia. To definitively exclude the presence of an intracardiac shunt or thrombi, an intraoperative 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 calcification 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: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.03.006 Key words: aortic thrombus, arterial embolism 1176
(Video clip 1). Complex immobile atheroma/calcifications were also observed in the entire descending aorta. Of note, as opposed to the CT angiography results, intraoperative TEE identified 2 mobile echo densities of considerably large size. INTRAOPERATIVE COURSE
Due to the nature of her problems, the authors pursued a multi-disciplinary intraoperative approach. The cardiac surgical team was consulted emergently for their opinion regarding the management of the aortic thrombus. According to the cardiac surgical opinion, the position of the thrombus precluded it from adequate surgical resection without deep hypothermic circulatory arrest. They suggested that the risk-benefit ratio in this particular case favored long-term anticoagulation with close followup to assess for recurrence of embolism. ECHOCARDIOGRAPHIC CHALLENGES
Should intraoperative TEE be performed routinely in cases of acute upper and lower limb ischemic episodes to exclude a cardiac source of thrombus? CLINICAL CHALLENGES
What should the clinical course of management be in cases with unanticipated findings on the TEE examination?
Fig 1. Mobile echogenic density on the posterior wall of the distal aortic arch.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 1176–1177
1177
GARCIA-JACQUES ET AL
Considering the risk of embolism, should the clinicians involved in this patient’s care exercise therapeutic privilege and proceed with additional procedures for which the patient not consented? Do such intraoperative diagnoses and management decisions based on unanticipated echocardiographic findings fall within the purview of basic intraoperative echocardiography? CLINICAL COURSE
Consequently, after the embolectomy, the patient was maintained 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 identification of the source of emboli has been established in the past.1–3 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 benefit evaluation. Most importantly, a consensus is needed from the involved anesthesiologist and
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 complications. 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 demonstrated findings 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 difficulty 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.
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
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
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
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 absence of radial and ulnar pulses was noted, and a heparin infusion immadiately was started. Within 30 minutes of the initiation of heparin, there was improvement in her symptoms without restoration of palpable pulses, and she was transferred urgently to the authors’ hospital. The patient had a remote history of an acute episode of lower limb ischemia. She had been non-compliant with her medications and reported discontinuing her daily aspirin 3 months prior to the current episode of upper extremity ischemia. On a transthoracic echocardiogram performed during the workup at the authors’ hospital, she had normal biventricular systolic function and an enlarged left atrium. Due to the suboptimal nature of the transthoracic echocardiography study, an intracardiac shunt 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 flow distal to the obstruction. Computed tomographic (CT) thoracic angiogram revealed a calcified ovoid filling defect of 1 cm 0.7 cm adherent to the inferior aortic wall at the level of the left subclavian artery ostium. Due to continued absence of distal pulses despite heparin infusion, an emergent ulnar artery thrombectomy was performed under general anesthesia. To definitively exclude the presence of an intracardiac shunt or thrombi, an intraoperative 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 calcification 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: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.03.006 Key words: aortic thrombus, arterial embolism 1176
(Video clip 1). Complex immobile atheroma/calcifications were also observed in the entire descending aorta. Of note, as opposed to the CT angiography results, intraoperative TEE identified 2 mobile echo densities of considerably large size. INTRAOPERATIVE COURSE
Due to the nature of her problems, the authors pursued a multi-disciplinary intraoperative approach. The cardiac surgical team was consulted emergently for their opinion regarding the management of the aortic thrombus. According to the cardiac surgical opinion, the position of the thrombus precluded it from adequate surgical resection without deep hypothermic circulatory arrest. They suggested that the risk-benefit ratio in this particular case favored long-term anticoagulation with close followup to assess for recurrence of embolism. ECHOCARDIOGRAPHIC CHALLENGES
Should intraoperative TEE be performed routinely in cases of acute upper and lower limb ischemic episodes to exclude a cardiac source of thrombus? CLINICAL CHALLENGES
What should the clinical course of management be in cases with unanticipated findings on the TEE examination?
Fig 1. Mobile echogenic density on the posterior wall of the distal aortic arch.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 1176–1177
1177
GARCIA-JACQUES ET AL
Considering the risk of embolism, should the clinicians involved in this patient’s care exercise therapeutic privilege and proceed with additional procedures for which the patient not consented? Do such intraoperative diagnoses and management decisions based on unanticipated echocardiographic findings fall within the purview of basic intraoperative echocardiography? CLINICAL COURSE
Consequently, after the embolectomy, the patient was maintained 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 identification of the source of emboli has been established in the past.1–3 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 benefit evaluation. Most importantly, a consensus is needed from the involved anesthesiologist and
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 complications. 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 demonstrated findings 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 difficulty 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.
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
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
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
