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Management and clinical outcome of concomitant pulmonary embolism and paradoxical saddle aortic arch embolism
  1. Enrico Mancuso1,
  2. Andrew Philip Winterbottom2,
  3. Jonathan R Boyle3 and
  4. Diane R Hildebrand3
  1. 1 Vascular Surgery, Addenbrooke’s Hospital, Cambridge, UK
  2. 2 Radiology, Addenbrooke’s Hospital, Cambridge, UK
  3. 3 Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  1. Correspondence to Enrico Mancuso, en.mancuso{at}


A 65-year-old man presented in a peri-arrest situation after collapse, he was found hypoxic with ischaemic arms. CT imaging showed massive bilateral pulmonary embolisms (PEs) and an aortic arch embolus extending from brachiocephalic trunk to left subclavian artery. Following intravenous thrombolysis, repeat imaging revealed that the aortic embolus had migrated distally into both axillary arteries and had occluded the right carotid from origin to skull base. Bilateral upper limb embolectomies were carried out from the brachial arteries together with forearm fasciotomies. Left hemianopia related to a right middle cerebral artery territory infarct was managed conservatively; forearm fasciotomy wounds were primarily closed and the patient was discharged on lifelong anticoagulation. A transoesophageal echocardiogram revealed a patent foramen ovale. This case demonstrates a very unusual presentation of concomitant PE and paradoxical saddle aortic arch embolism. A multidisciplinary approach has resulted in an excellent clinical outcome for this complex patient.

  • vascular surgery
  • pulmonary embolism
  • radiology
  • stroke
  • adult intensive care

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  • Contributors DRH is the main supervisor of this article, being in charge of contents and objectives. EM gave the substantial contributions in writing, designing the paper and analysis of the available data. APW, consultant radiologist, provided imaging and reviewed related drafts. JRB critically revised the work for important intellectual content. Final approval of the published was shared by every author after individual revision, in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Patient consent for publication Obtained.

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