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Niazi M, Khan D, Mustafa A, Munir AB, Karam B, Snyder ST, Lafferty J. Left Atrial Thrombus Mimicking Myxoma Secondary to Rebound Hypercoagulable State. J Med Cases 2021; 12:243-247. [PMID: 34434465 PMCID: PMC8383509 DOI: 10.14740/jmc3656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Novel oral anticoagulants (NOACs) have made the use of anticoagulation in patients with atrial fibrillation (AFib) much more convenient and predictable. It is a very common practice to hold anticoagulation either in anticipation of surgical procedures (to prevent excessive bleeding) or in case of acute bleeding episodes. This abrupt withdrawal of anticoagulation tilts the balance in favor of pro-thrombotic state in the body. We present a case of a 60-year-old man with past medical history of AFib who abruptly discontinued his apixaban (Eliquis). This patient presented to emergency room with the complaint of weakness and numbness of left arm and left half of the face. Stroke code was activated, and patient received tissue plasminogen activator (t-PA). This resulted in significant improvement of symptoms within hours of receiving treatment. Later during the same day, patient developed numbness and tingling of fingers of left hand. On physical exam, left hand was cold to touch and radial pulse was absent. Arterial duplex revealed occluded ulnar and radial arteries. Vascular surgery performed embolectomy to establish blood flow in the radial and ulnar arteries. Transthoracic echocardiogram revealed large left atrial mass attached to the atrial septum. Most likely t-PA infusion in the setting of atrial mass led to distal showering of emboli resulting in stenosis of radial and ulnar arteries. The left atrial mass was most likely thrombus as patient had cardiac imaging including transthoracic echocardiogram and computed tomography of heart prior to these events which did not reveal any mass in left atrium. In short, as clinicians we should be aware of the hypercoagulability associated with withdrawal of anticoagulation. In addition, we should be wary of the challenges associated with differentiating cardiac masses of different etiology.
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Affiliation(s)
- Muhammad Niazi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Danyal Khan
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Ahmad Mustafa
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Abdullah B Munir
- Department of Cardiology, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Boutros Karam
- Department of Cardiology, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Stavros T Snyder
- Department of Cardiology, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - James Lafferty
- Department of Cardiology, Staten Island University Hospital/Northwell Health, 475 Seaview Ave., Staten Island, NY 10305, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Chan KH, Ramahi A, Lim SL, Ahmed E, Suleiman A, Slim J, Shaaban HS. Left ventricular thrombus complicated by acute limb ischemia in a patient with HIV. Radiol Case Rep 2021; 16:2416-2420. [PMID: 34257771 PMCID: PMC8260751 DOI: 10.1016/j.radcr.2021.05.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/01/2022] Open
Abstract
Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.
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Affiliation(s)
- Kok Hoe Chan
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Amr Ramahi
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Su Lin Lim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Eyad Ahmed
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Addi Suleiman
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Cardiology, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Jihad Slim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Hamid S Shaaban
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Hematology/Oncology, Saint Michael's Medical Centre, New York Medical College, NJ, USA
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Atkins E, Wallace R, Johnson L, Puckridge P. Arterial embolization of metal-on-metal hip arthroplasty-related pseudotumor material causing acute limb ischemia. J Vasc Surg Cases Innov Tech 2021; 7:399-402. [PMID: 34278068 PMCID: PMC8261463 DOI: 10.1016/j.jvscit.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/19/2021] [Indexed: 12/03/2022]
Abstract
We have described a complication of a pseudotumor secondary to metal-on-metal hip arthroplasty. The patient experienced acute limb ischemia after pseudotumor material had invaded and stenosed the external iliac artery and embolized distally. Multiple vascular surgery procedures were performed to revascularize the limb. The present report highlights the importance of involving vascular surgeons early in a limb-threatening presentation of a pseudotumor to achieve limb salvage.
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Affiliation(s)
- Eleanor Atkins
- Department of Vascular Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Rob Wallace
- Department of Orthopaedic Surgery, Sportsmed South Australia, Adelaide, South Australia, Australia
| | - Luke Johnson
- Department of Vascular Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Phillip Puckridge
- Department of Vascular Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
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Langenskiöld M, Smidfelt K, Karlsson A, Bohm C, Herlitz J, Nordanstig J. Weak Links in the Early Chain of Care of Acute Lower Limb Ischaemia in Terms of Recognition and Emergency Management. Eur J Vasc Endovasc Surg 2017; 54:235-240. [PMID: 28583719 DOI: 10.1016/j.ejvs.2017.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/15/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Acute lower limb ischaemia (ALLI) is a potentially fatal, limb threatening medical emergency. Early treatment is essential for a good outcome. The aim was to describe the early chain of care in ALLI focusing on lead times and emergency management in order to identify weak links for improvement. METHODS This was a retrospective, descriptive case study. This study analysed the medical records of all patients with a main discharge diagnosis of ALLI between January 2009 and December 2014. Predetermined emergency care data on lead times, diagnosis recognition, presenting symptoms, emergency care treatment and outcome were collected for patients who were transported by the Emergency Medical Service (EMS) and those who were not. RESULTS In total, 552 medical records were audited of which 195 patients fulfilled the inclusion criteria and were analysed. Among them were 117 (60%) transported by the EMS. The median time from symptom onset to revascularisation was 23 (interquartile range [IQR] 10-55; EMS transported) and 93 (IQR 42-152, not EMS transported) hours (p < .01). The time from symptom onset to arrival in hospital was 5 (IQR 2-26; EMS transported) and 48 (IQR 6-108; not EMS transported) hours. After arrival in hospital, the median time to first doctor evaluation was 51 (IQR 28-90; EMS transported) and 80 (IQR 44-169; not EMS transported) minutes, p = .01. Low molecular weight heparin (LMWH) was given to 72% of patients in the emergency department (ED) and a multivariate analysis showed that the use of LMWH was associated with a more favourable outcome. CONCLUSIONS Both the time spent in the ED and the time from the onset of symptoms to revascularisation were considerably longer than optimal. Time delays in the early treatment chain can mainly be attributed to "patient delay" and a considerable time spent in hospital before revascularisation. The use of LMWH as an integral part of ED management was associated with a better outcome.
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Affiliation(s)
- M Langenskiöld
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department for Molecular and Clinical Medicine, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - K Smidfelt
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department for Molecular and Clinical Medicine, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - A Karlsson
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department for Molecular and Clinical Medicine, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - C Bohm
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department for Molecular and Clinical Medicine, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - J Herlitz
- The Centre for Pre-Hospital Research, University of Borås, Borås, Sweden
| | - J Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department for Molecular and Clinical Medicine, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
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