Paradoxical Embolism Causing Acute Limb Ischemia Initially Diagnosed on Point of Care Ultrasound

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-9-2025

Abstract

Upper extremity acute limb ischemia (ALI) is a time sensitive diagnosis that can result in disability and loss of limb or life. Classical symptoms of ALI include pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis. Lower extremity ischemia is much more common than upper limb ischemia and is mainly caused by atherosclerosis. The most common cause of upper extremity ALI is thromboembolism, usually secondary to atrial fibrillation, valvular heart disease, and much less commonly paradoxical embolism. While most cases can be diagnosed based on history and physical exam, there are many vascular imaging modalities with catheter-based arteriography being the gold standard. We present a case of an elderly female with upper extremity acute limb ischemia from axillary artery thrombosis, that was diagnosed on point-of-care ultrasound (POCUS) in a rural emergency department (ED).

An elderly female with a history of hypertension, hyperlipidemia, and dementia presented to a critical access ED overnight with right shoulder pain after 3 falls. On exam, she was in no acute distress but was unable to move her right hand and wrist with a subtle discoloration and coolness of the right hand. Vital Signs: T 36.5, HR 91, RR 20, BP 133/65, SpO2 84% on room air. POCUS was performed a few minutes after arrival that revealed a right axillary artery thrombosis and right ventricular strain with suspected pulmonary embolus. Based on the sonographic findings, heparin was started and the EM physician expedited transfer to a tertiary care center. Length of stay was a total time of 77 minutes at the critical access ED. CT angiogram of the thorax confirmed a right subclavian artery thrombosis and moderate pulmonary emboli burden with right heart strain as well as revealed right popliteal deep vein thrombosis. Notable labs: WBC 19.1, lactic acid 3.8, troponin 158, BNP 11,114.

Upon arrival to the tertiary care center, vascular surgery and interventional radiology were consulted and the Pulmonary Embolism Response Team was called. She underwent emergent open thrombectomy of the right upper extremity with removal of significant thrombus in the right brachial and radial arteries less than 8 hours after arrival to initial facility. A femoral atrial line was placed for hemodynamic monitoring. Heparin was continued post-procedure. A few hours after the thrombectomy, she developed a right groin hematoma and hypotension. Heparin was discontinued for a brief period and then restarted. Despite an initial PERT Team recommendation for a PE thrombectomy, she was no longer a candidate given co-morbidities and recent bleeding complication. A complete echo revealed an EF of 65%, interatrial shunt, and a McConnell's sign. She was transferred out of the ICU on day 4 and then discharged on day 10 on Eliquis. About two weeks after discharge, she developed a GI bleed that eventually led to her death.

Acute limb ischemia is less common in the upper extremities, yet still time-sensitive and life and limb threatening. Given the patient's pulmonary embolism, deep vein thrombosis, and confirmed interatrial shunt, a paradoxical embolism is the probable cause of her axillary artery thrombosis. This case illustrates a unique cause of acute limb ischemia that was initially identified on POCUS that expedited time to diagnosis and definitive management.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1697

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