An unusual presentation of aortic saddle embolus
================================================

* Jonathan Yap
* Yeow Leng Chua
* Aaron Wong

*   Aorta, Great Vessels and Trauma
*   Imaging and Diagnostics

Aortic saddle embolus often presents with acute lower limb ischaemia or neurological deficits.1 ,2 Other unusual presentations may occasionally be encountered.

A 60-year-old woman with a history of an old anterior myocardial infarction presented to the emergency department with acute pulmonary oedema. The ECG showed non-specific ST abnormalities with slightly raised cardiac enzymes. An urgent coronary angiogram was performed to rule out cardiac causes for her presentation. During the procedure, the femoral pulse was poorly felt. The coronary angiogram showed triple vessel disease but no acute coronary occlusion. The aortogram showed a totally occluded aorta distal to the renal arteries (figure 1A). This was also visualised on abdominal aorta ultrasound (figure 1B). A vascular consultation was sought and the patient underwent urgent bilateral aortoiliac embolectomy with a Fogarty catheter. Multiple clots were removed from the distal aorta and iliac arteries (figure 1C). A transthoracic echocardiogram subsequently showed multiple thrombi at the left ventricular apex (figure 1D), the likely source of the emboli. The patient died 10 days later from sepsis.

![Figure 1](http://heartasia.bmj.com/https://heartasia.bmj.com/content/heartasia/6/1/10/F1.medium.gif)

[Figure 1](http://heartasia.bmj.com/content/6/1/10/F1)

Figure 1 
(A) Aortogram showing a completely occluded aorta (white arrow) distal to the renal arteries. (B) Vascular ultrasound showing acute thrombus (white arrow) in the distal aorta. (C) Thrombi extracted during embolectomy. (D) Apical four-chamber view on transthoracic echocardiogram showing multiple thrombi (red cross) in the left ventricular apex.

Acute lower limb ischaemia or paraplegia are the commonest presentations of aortic saddle embolus.1 ,2 Interestingly, our patient did not complain of any lower limb symptoms but presented instead with cardiac failure. The pulmonary oedema was probably caused by the sudden increase in afterload from the acute occlusion resulting in back-damming of blood. We report an uncommon presentation of aortic saddle embolus with acute pulmonary oedema, together with rarely seen detailed multimodality imaging.

## Footnotes

*   Contributors All three authors contributed to the design and drafting of the manuscript.

*   Competing interests None.

*   Patient consent Obtained.

*   Provenance and peer review Not commissioned; externally peer reviewed.

## References

1.  Busuttil RW, Keehn G, Milliken J, et al. Aortic saddle embolus. A twenty-year experience. Ann Surg 1983;197:698–706.
    
    [PubMed](http://heartasia.bmj.com/lookup/external-ref?access_num=6859979&link_type=MED&atom=%2Fheartasia%2F6%2F1%2F10.atom) 

2.  Surowiec SM, Isiklar H, Sreeram S, et al. Acute occlusion of the abdominal aorta. Am J Surg 1998;176:193–7.
    
    [CrossRef](http://heartasia.bmj.com/lookup/external-ref?access_num=10.1016/S0002-9610(98)00129-9&link_type=DOI) 
    
    [PubMed](http://heartasia.bmj.com/lookup/external-ref?access_num=9737631&link_type=MED&atom=%2Fheartasia%2F6%2F1%2F10.atom) 
    
    [Web of Science](http://heartasia.bmj.com/lookup/external-ref?access_num=000075737200023&link_type=ISI)