An Unusual Source of Systemic Thromboembolism

Abstract

Pulmonary vein thrombosis (PVT) is a rare but potentially life threatening condition. This is a case of pulmonary vein thrombosis presenting with systemic thromboembolism despite treatment with anticoagulation. A 73-year-old woman, with past medical history of hypertension, peripheral arterial disease (PAD), and treated endometrial and breast cancer, presented with complaint of pain in her right foot of one-day-duration. She had a history of PVT diagnosed on chest CT angiogram one month prior to presentation, which was done to exclude pulmonary embolism when she presented with progressively worsening dyspnea. Physical examination was notable for an elderly woman in painful distress, with a cold, pulseless right foot with bluish discoloration of the skin of the forefoot and a clear line of demarcation from the proximal foot. The angiogram revealed occlusion of the right popliteal artery just above the knee with no appreciable blood flow within the distal vessels. Contrast CT of the abdomen and pelvis revealed multiple hypo-enhancing ill-defined hepatic masses, bilateral adrenal masses and mediastinal adenopathy. Echocardiogram revealed a large left ventricular thrombus and hyper-dynamic left ventricular systolic function. She was admitted for acute right foot ischemia and underwent popliteal exploration, open thrombectomy and embolectomy with restoration of pedal flow. However, she had repeat right popliteal exploration two days later due to further ischemic changes in the foot. Post-operatively, she developed multi-organ dysfunction including respiratory failure requiring endotracheal intubation and mechanical ventilation. She was terminally weaned from mechanical ventilation on request by her family and she died on the sixth day of admission. This case describes the occurrence of systemic embolization despite anticoagulation for pulmonary vein thrombosis. The large thrombus found in the left ventricle most likely represents a thrombus in transit from the superior left pulmonary vein en-route systemic embolization with consequent multi-organ dysfunction.