Absent Femoral Pulses Research Articles

Window entrapment trauma in cats: clinical, neurological and clinicopathological findings and outcome (70 cases).

Window entrapment in cats can lead to reduced blood flow to the spinal cord, muscles and nerves, resulting in ischaemic neuromyelomyopathy. The severity and duration of entrapment greatly influence clinical and neurological outcomes, as well as prognosis. The aim of the present retrospective multicentric study (2005-2022) was to describe clinical, neurological and selected clinicopathological findings, as well as the outcome of cats trapped in bottom-hung windows, presented to both first-opinion and referral-only clinics. The study included cats with detailed clinical and neurological evaluations at admission, along with at least one of the following biochemical parameters: creatine kinase (CK), aspartate transaminase (AST), alanine aminotransferase (ALT) activities, urea and/or creatinine. Clinical and neurological parameters evaluated in the study included rectal temperature, femoral pulse, gait, urinary bladder function, tail function and survival to discharge. Odds ratios (ORs) were calculated for survival and each clinical, neurological and biochemical variable. Of the 70 cats that met the inclusion criteria, only seven (10%) died or were euthanased during hospitalisation. Nevertheless, with the available data, we found evidence of an association between clinical and neurological status and survival, with tail function being the strongest association. Cats lacking tail sensation, motor function and/or tonus were more likely to die than cats with normal tail function or only mild abnormalities (OR = 24). Similarly, cats with severe hypothermia or an absent femoral pulse were less likely to survive (OR = 12.75 and 7.5, respectively). In this sample (with a relatively low number of deaths), we did not find evidence of an association between CK, AST and ALT activity with survival. However, the only two cats with severe increases in creatinine died. Assessment of gait, urinary bladder function, femoral pulse, rectal temperature and particularly tail function is promising for predicting outcomes in cats with window entrapment trauma.

Un-diagnosed coarctation of the aorta in a 27-year-old adult with a rare presentation: a rare case report

Introduction and importance: Coarctation of the aorta (COA) is a rare form of congenital heart disease that is typically diagnosed in children. COA is known to present with hypertension, weak or absent femoral pulses, heart failure in older patients, but the presentation of COA as calf atrophy is extremely rare. This article reports the successful surgical repair of a 27-year-old adult with undiagnosed COA. Case presentation: A 27-year-old-male has presented with calf atrophy, which was diagnosed as COA transthoracic echocardiography and computed tomography angiography indicate COA, which is treated with successful surgical repair. Clinical discussion: COA is typically diagnosed in children with a rare incidence in adults. Calf atrophy is an extremely rare presentation and uncommon. He has calf atrophy, which led to the diagnosis of COA in 27 years. The presentation in this medium-aged population with this rare manifestation gives our case significance to be one of the unique reported cases. Conclusion: COA is uncommon to be found in adults and the presentation with calf atrophy is even rare. The authors revealed that COA can be found in adults and with an unexpected manifestation and highlights the significance of early detection, and timely referral to a specialist can enable proper management, which includes surgical correction.

Coarctation of aorta in a young female with extensive collaterals presenting with secondary hypertension

Coarctation of aorta is a common condition usually diagnosed during childhood. During adulthood they are usually diagnosed during evaluation of secondary hypertension or resistant hypertension. We report a case of young female who was asymptomatic and found to have high blood pressure during routine clinical evaluation. During physical examination she had absent femoral pulses which lead to suspicion of presence of coarctation. She underwent surgical procedure with interposition graft. After follow up of one year she is doing well and her blood pressure under control with a single medication.

Open aortic reconstruction for middle aortic syndrome associated with right renal artery poststenotic aneurysm.

A 24-year-old woman was diagnosed with high blood pressure when she was 14 years old. During the last 4 years, she has experienced progressive symptoms of lower extremity weakness and fatigue and cannot do any heavy exercise. On physical examination, she presented with absent bilateral femoral pulses. Ultrasound ankle-brachial index (ABI) with Doppler of the lower extremities showed diffuse monophasic waveforms and diminished ABI bilaterally (right ABI = 0.68, left ABI = 0.65). A computed tomography angiography confirmed a severe narrowing of the aorta just distal to the origin of the left renal artery consistent with the diagnosis of middle aortic syndrome.

Acute Thromboembolism from Trauma in a Patient with Abdominal Aortic Aneurysm.

Case PresentationA 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator.DiscussionAcute thrombosis of AAA and subsequent thromboembolic events are a rare but significant complication that can occur in patients with a history of AAA. Thromboembolic events may occur spontaneously or in the setting of blunt abdominal trauma. Common presenting signs and symptoms include distal limb ischemia and absent femoral pulses. Timely management and recognition of this rare complication is vital as this condition can ultimately result in limb loss or death if not treated in a timely manner. Heparinization after confirmation of non-ruptured AAA as well as vascular surgery, and therapeutic and vascular interventional radiology consultations are key steps that should be taken to decrease patient morbidity and mortality.

Middle aortic syndrome: high index of suspicion should be kept in mind

A woman in her early 50s with a history of poorly controlled hypertension was admitted to the intensive care unit for an electrical storm complicating an anterolateral myocardial infarction. After...

Late diagnosis of coarctation of the aorta in a 44-year-old male: a case report

BackgroundCoarctation of the aorta is a rare congenital disease. In adults, the main manifestations include hypertension, weak or absent femoral pulses, heart failure, and left ventricular hypertrophy.Case presentationWe present a case involving a late diagnosis of coarctation of the aorta detected during aortography in a 44-year-old man. The patient underwent stent implantation and aortoplasty. After 2 years of follow-up, the patient was in good condition.ConclusionsThis case shows that coarctation of the aorta can be cured and that hypertension caused by the condition can be controlled to some extent with medication. Based on our findings, we recommend a detailed physical examination for all patients suspected of having coarctation of the aorta; the examination should include blood pressure measurements of both the upper and lower extremities. The case of coarctation of the aorta is not common or easy to be found in medium-aged population. Better BP control, earlier repair, and transcatheter intervention may result in a good outcome in that case.

The persistent sciatic artery: Report of ten cases.

The persistent sciatic artery (PSA) is a rare congenital anomaly with a high rate of aneurysm formation, occlusion and stenosis. It may lead to severe complications including thrombosis, distal embolisation, or aneurysm rupture. We reported herein our experience in the management of PSA and its complications, and discuss the therapeutic options. Eight patients with 10 PSA were managed in our institutions between 1985 and 2017. An analysis was done for the clinical data, surgical technique, and results. The series included six women and two men. The median age of the patients was 66,5 years (37-80 years). Physical examination found a pulsatile gluteal mass in five patients, sciatic neuropathy in two cases. Four patients had an acute ischemia of the lower limb. Cowie's sign was described in only two patients (diminished or absent femoral pulse but presence of popliteal pulse). Digital subtraction angiography was performed in all patients, and was completed with a computed tomography angiography (CTA) with a diagnosis of PSA, associated with a symptomatic aneurysmal lesion in seven cases and with an occlusion in one case. The treatment was surgical in all cases: bipolar exclusion of the aneurysm and bypass between the iliac artery and the PSA distal to the aneurysm was performed in four cases, only proximal and distal ligation was done in 2 other cases. A Chopart amputation was necessary in 2 cases. We consider that the treatment of PSA is usually surgical in symptomatic cases. Surgical techniques depend on symptoms and classification describing anatomy of the PSA. However, future studies should compare the open versus the endovascular approach to optimize patient selection criteria and identify the most safe and effective strategy. In an asymptomatic patient, PSA does not require any intervention; continued follow-up is required because of the high incidence of aneurysmal formation and the risk of thromboembolic events.

Diagnostic values of the femoral pulse palpation test

ObjectivesTo calculate diagnostic values of the femoral pulse palpation to detect coarctation of the aorta or other left-sided obstructive heart anomalies in newborn infants.DesignPopulation-based cohort study.SettingStockholm-Gotland County 2008–2012.PatientsAll singleton live-born...

Metoda plastyki łuku aorty z zachowaniem przewodowego przepływu systemowego w leczeniu krytycznej koarktacji o morfologii bovine trunk

Introduction. Coarctation of the aorta is a congenital heart defect defined as aortic narrowing at the isthmus. It may occur in association with other defects, which requires a discussion regarding the choice of optimal therapy. Critical aortic coarctation with aortic hypoplasia and so-called bovine trunk anatomy is one of the more challenging forms of this defect, characterized by a common origin of the brachiocephalic trunk and the left common carotid artery, which form a common vessel extending as a direct continuation of the ascending aorta. Therapeutic decisions are made depending on the distance between the ascending aorta and the isthmus and descending aorta, taking into account the typical management of hypoplastic aortic arch. Material and methods. The clinical presentation in the neonatal period includes weak or absent femoral pulse, pallor, apathy, dyspnea and signs of systemic hypoperfusion with progressive lung edema and acidosis. The diagnosis is mostly based on echocardiography while magnetic resonance imaging or computed tomography allow detailed imaging of the collateral vessels. The most important diagnostic issues are the anatomy of the defect, severity of concomitant aortic isthmus narrowing, and its hemodynamic effect. The medical management is directed at maintaining patency of the ductus arteriosus with prostaglandin E1 infusion and an appropriate balance between peripheral systemic and pulmonary resistance. The recommended treatment of choice is an early surgical correction of the aortic arch defect. The aortic arch reconstruction method with ductus-dependent systemic flow preservation implies resection of the coarctation along with the isthmus narrowing and proximal end-to-side anastomosis, with reconstruction of the inflow to the left subclavian artery using a hypoplastic distal segment of the aortic arch. The operation is performed by the left posterolateral thoracotomy without using extracorporeal circulation. Conclusions. The prerequisite for selecting a neonate for the proposed procedure is a detailed assessment of aortic arch anatomy, with particular attention to the measurement of the distance between the ascending aorta and the area where the ductus arteriosus connects to the descending aorta. The major advantage of this technique is the ability to perform an off-pump procedure via the lateral access, using only healthy native patient tissues for aortic flow restoration.

Delayed Presentation of Traumatic Acute Limb Ischemia

Acute limb ischemia is defined as sudden cessation of limb perfusion that threatens the viability of the limb. Although uncommon, acute limb ischemia can present with severe symptoms. We present the case of a 23-year-old male who was admitted for treatment of abdominal gunshot injury. Laparotomy revealed multiple transections of the small bowel with a non-expanding zone 2 retroperitoneal hematoma. Following resection of the damaged bowel, 12 hours postoperatively, the patient complained of right lower limb numbness. Examination revealed absent right femoral, popliteal, dorsalis pedis and posterior tibial pulses, with a capillary refill time (CRT) of 3 seconds. Computed tomography arteriogram (CTA) showed right external iliac artery thrombosis, with reconstitution of flow in the distal external iliac artery. Repeat laparotomy showed a peri-arterial hematoma of the right external iliac artery distal to the common iliac bifurcation. We removed a 3 cm thrombus from the right external iliac artery and performed an interposition graft. Following surgery, all the lower limb pulses were palpable and the patient was discharged in good condition on postoperative day 6. Delayed presentation of acute limb ischemia is possible in the setting of trauma, and should be kept in mind, as timely intervention is important for limb salvage with good outcome.

Genetic testing for coarctation of aorta

Abstract Coarctation of the aorta (CoA) is an inherited narrowing of the proximal descending thoracic aorta. Histological features include localized medial thickening and infolding with superimposed neointimal tissue. CoA is diagnosed by detection of a murmur or hypertension during routine examination. Typical clinical features are delayed or absent femoral pulses and difference in blood pressure between the arm and legs. These symptoms may appear in the first weeks of life or after the neonatal period. CoA accounts for 4-6% of all congenital heart defects and has a reported prevalence of about 4 per 10,000 live births. It is more common in males than females (59% vs 41%). This Utility Gene Test was developed on the basis of an analysis of the literature and existing diagnostic protocols. It is useful for confirming diagnosis, as well as for differential diagnosis, couple risk assessment and access to clinical trials.

Safety and Feasibility of Transradial Access for Noncoronary and Peripheral Vascular Interventions

Transradial access (TRad) is becoming the preferred access for cardiac catheterization. The use and safety of TRad in noncoronary and peripheral vascular interventions remains ill-defined and serves as the basis for this study. Patients undergoing noncoronary and peripheral endovascular procedures via TRad from August 2010 to February 2013 at our institution were reviewed retrospectively. Demographic data, indications, interventions performed, sheath size, procedural outcomes, and access-site complications were evaluated. Postprocedural radial artery patency and hand ischemic symptoms were evaluated clinically and by duplex ultrasound. Nineteen patients underwent 24 procedures via TRad for both diagnostic (11/24) and therapeutic (13/24) purposes. Twelve (63%) were women, and 75% (18/24) were from left radial artery. Indications included absent femoral pulses in 12 (50%), morbid obesity in 6 (25%), previous bypass originating or terminating in the groin in 4 (17%), and groin wound infection in 2 (8%) cases. A 5F sheath was used in 13 (54%) cases, 6F in 10 (42%) cases, and 7F in 1 (4%) case. Thirteen therapeutic interventions included 7 (29%) iliac angioplasties and/or stent, 3 (13%) femoral anastomosis angioplasties, 2 (8%) superficial femoral artery angioplasties, and 1 (4%) mesenteric angioplasty. No access-site hematoma or procedure-related deaths were reported. Postprocedural radial artery occlusion was observed in 6 (31%) patients. All occlusions were asymptomatic, except for 1 (4%) patient with self-limiting forearm pain lasting for 1day. Sheath size strongly correlated with radial artery occlusion. TRad appears to be a safe and feasible alternative option for patients undergoing noncoronary and peripheral interventions. Radial artery occlusion, mostly asymptomatic, can occur and is directly related to the sheath size. Smaller sheath sizes, longer platform devices, better radial access kits, and better closure devices could potentially eliminate some of the challenges associated with TRad.

Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report

BackgroundAortoiliac occlusive disease, which is also referred to as Leriche syndrome, is a chronic atherosclerotic occlusive disease that occurs at the level of the aortic bifurcation. It is often thought to present with a triad of clinical symptoms: (1) intermittent lower extremity vascular claudication, (2) impotence, and (3) weak/absent femoral pulses.Case presentationWe report a case of a 47-year-old Caucasian woman who presented with an acute inferior ST-elevation myocardial infarction. During percutaneous transluminal angioplasty, our patient suddenly developed severe bilateral lower extremity pain, absent femoral pulses, and cool extremities. Distal aortogram revealed 95% stenosis with an apple core-like lesion in the mid-abdominal aorta. Stent placement resulted in improved blood flow to the distal aortic segment and resolution of symptoms.ConclusionsThe presence of significant peripheral vascular disease, significant cardiac risk factors, and/or difficulty accessing the femoral artery should caution a transfemoral approach during percutaneous transluminal angiography. This approach may precipitate aortoiliac occlusion and/or thromboembolism to the lower extremities. We encourage interventional cardiologists to (1) take extra caution when manipulating the wire and catheter and (2) strongly consider using a transradial approach in such patients.

Recombinant Tissue Plasminogen Activator Therapy for Aortic Thromboembolism in Four Dogs

Four dogs were brought to the Veterinary Medicine Teaching Hospital of Seoul National University (VMTH SNU) with a history of hind limb ataxia, three with pain, one without pain. Three of the four showed weak to absent femoral pulses and cold extremities. Thromboembolism was identified by ultrasonography in the external and/or internal iliac arteries. A thrombolytic agent, recombinant tissue plasminogen activator (rt-PA), was administered (0.5-1 mg/kg, every 60-120 min, 3-5 doses). Two dogs (Cases 2 and 3), which were instantly provided rt-PA treatment, survived 6 and 17 months, respectively, although hematemesis and hematochezia were observed during treatment. In the other two dogs (Cases 1 and 4), rt-PA was administered 4 and 28 days after the appearance of pelvic limb symptoms, which may have limited the benefits of the treatment. When rt-PA treatment is instituted instantly and the side effects are monitored thoroughly during treatment, a good prognosis might be expected in canine aortic thromboembolism. For this reason, we suggest that rt-PA treatment should be initiated immediately if thromboembolism is identified.

Use of the AndraStent XL and XXL for the treatment of coarctation of the aorta in children and adults: immediate and midterm results.

The aim of this study is to present our experience with a new type of extra-large stent, namely the AndraStent XL/XXL. AndraStents were implanted in 46 patients, 38 with native coarctation of the aorta (CoA) and eight with recurrent coarctation of the aorta following previous surgery (ReCoA). All patients had arterial hypertension in the upper limbs, absent or weak femoral pulses, and continuous flow in the abdominal aorta on Doppler examination. The median age of patients was 25 years (range from nine to 65). The stents (cobalt-chromium with semi-open cell design) were manually mounted on balloon catheters and delivered through 10 to 14 Fr Mullins sheaths using a conventional femoral approach. All procedures were successful (no stent migration, proper expansion, no aorta dissection/rupture, major bleeding or major vessel injury). The systolic gradient across the aorta decreased from 40.6 mmHg before the procedure to 11.6 mmHg after the procedure (p<0.001). The mean fluoroscopy time was 5.7 minutes. Imaging examinations were scheduled and performed between six and 12 months after the initial procedure in 40 patients (angiography or angio CT or both). Procedural outcome remained favourable during a mean 2.4 years of follow-up. Neither stent fracture nor dislocation was observed in any patient at follow-up. In two patients, small aneurysm formation was observed six and eight months after the procedure -they were treated successfully with subsequent covered stent implantation. Re-dilatation of the implanted stent was performed between four and 26 months in 14 patients. Implantation of new large cobalt-chromium stents is a good therapeutic option for the treatment of native and recurrent CoA.

Prediction of systolic blood pressure using peripheral pulse palpation in cats.

To evaluate the ability of peripheral pulse palpation to predict systolic blood pressure (SBP) in cats presenting as emergencies. Prospective observational study performed over an 8-month period. University veterinary teaching hospital. One hundred two cats presenting to the emergency service. Eligibility for inclusion in the study included a physical examination and a SBP via Doppler technique performed prior to treatment. None. Femoral and metatarsal pulses were digitally palpated and the quality of the pulses was assessed as either strong, moderate, poor, or absent. A concurrent SBP was also recorded. The median SBP for all cats was 92.5 mm Hg (range, 30-240 mm Hg). Femoral pulse quality was found to strongly correlate with the admission SBP (P < 0.001, rho = 0.6755). The median SBP for each femoral pulse quality category (strong, moderate, poor, or absent) was significantly different (P < 0.05). For metatarsal pulses, the median SBP for cats with either absent or strong pulses was significantly different (P < 0.001). Cats with absent metatarsal and femoral pulses had a median SBP of 30 mm Hg (range, 30-105 mm Hg), whereas cats with strong metatarsal pulses had a median SBP of 135 mm Hg (range, 58-210 mm Hg). Absent metatarsal pulses correctly identified cats with a blood pressure of 75 mm Hg or less 84% the time (area under the curve: 0.89, confidence interval 0.81, 0.97). In cats, peripheral pulse quality assessment by emergency room veterinarians correlates with SBP. With progressive decreases in blood pressure, metatarsal pulses will disappear and it is only with severe hypotension that femoral pulses are absent. An assessment of both dorsal metatarsal pulse and femoral pulse quality during triage may be useful in identifying abnormalities in blood pressure.

Sonographic Discovery of Leriche Syndrome and the Development of Collaterals

Leriche syndrome, also referred to as aortoiliac occlusive disease, is complete occlusion of the infrarenal aorta and bilateral common iliac arteries. The development of collateral pathways allows reconstitution of arterial blood flow to the lower extremities, preventing limb ischemia. Patients typically present with a triad of symptoms, which include intermittent claudication of the buttocks and thighs, decreased or absent femoral pulses, and impotence in men. Sonography may play a significant role in diagnosing Leriche syndrome, particularly in cases with contraindications to other more invasive tests. Knowledge of the presentation of aortoiliac occlusion along with recognition of developing collateral pathways assists with the diagnosis and management of this disease.

En bloc tibial thrombectomy

A 58-year-old man with hypertension and 40-pack year smoking history presented to the emergency department complaining of approximately 20 hours of right lower extremity pain. His initial symptom was shortdistance claudication, but quickly progressed to rest pain. Physical examination demonstrated right lower extremity pallor, delayed capillary refill, diminished sensation and strength, with absent femoral, popliteal, dorsalis pedis, and posterior tibial pulses. A pelvic and lower extremity computed tomography angiogram (CTA) revealed occlusion of the right common iliac artery with reconstitution at the level of the right common femoral artery from inferior epigastric artery, total occlusion of the popliteal artery, and no reconstitution distally. After heparinization, he emergently underwent iliac thromboembolectomy. Intraoperative angiography revealed residual thrombus in the proximal right common iliac artery which was treated with the placement of covered stents in the bilateral common iliac arteries. The below-knee popliteal artery was then exposed to address the occlusion seen on preoperative CTA (A). Using a Fogarty embolectomy catheter (Edwards Lifesciences, Irvine, Calif) and a DeBakey forceps through a transverse popliteal artery incision, one contiguous thrombus was removed en bloc, revealing a cast of the tibial trifurcation (B). The vessel was closed primarily and a palpable dorsalis pedis pulse was established. Given the duration of ischemia, a fourcompartment fasciotomy was performed. Postoperative workup demonstrated the source to most likely be a large mural thrombus in the visceral aorta (C). He is currently anticoagulated with warfarin. At 6-month follow-up, he reported ambulating near baseline, and had a palpable dorsalis pedis pulse with an ankle-brachial index of 1.1. Additionally, duplex imaging revealed widely patent vessels and follow-up CTA demonstrated near complete resolution of the aortic thrombus (D).

Lost and Found : Catastrophic en Block Embolism of a Mechanical Prosthetic Valve Thrombus after Thrombolytic Therapy

A 45-year-old woman presented with refractory pulmonary oedema secondary to a massive thrombosis of a St. Jude mechanical mitral prosthetic valve. She was noncompliant with warfarin and had suffered embolic stroke 3 years earlier, from which she had recovered. She was in sinus rhythm with absent valve clicks on auscultation. A transthoracic echocardiogram revealed a high transmitral peak gradient of 34 mmHg and a mean gradient of 27 mmHg with an ejection fraction of 55% [Figure 1A]. The international normalised ratio (INR) was 1.29. An urgent transesophageal echocardiogram (TEE) demonstrated a large (6 cm2) left atrial thrombus attached to the mechanical valve at the discs which were stuck in a closed position [Figures 1B and ​and1C1C]. Figure 1: (A) Transthoracic echocardiography showing mean diastolic mechanical mitral valve transvalvular gradient of 27 mmHg and a peak gradient of 34 mmHg in a patient with prosthetic valve thrombosis. (B) Transesophageal echocardiography demonstrating stuck ... The patient was advised to have emergency surgery, but she and the family refused. In spite of explaining the risks involved in thrombolysing a large clot, the patient and the family preferred thrombolytic therapy. As a life-saving measure, patient was thrombolysed with 10 units of reteplase intravenously over 2 minutes with a repeat dose of 10 units administered 30 minutes later. After an hour of thrombolysis a repeat TEE showed complete disappearance of the thrombus from the left atrium with one of the discs stuck in closed position [Figures 2 A and B]. The peak transmitral gradient was 7 mmHg and the mean gradient was 4 mmHg [Figure 2C]. Immediately, the patient started to complain of severe pain in the left leg with cold periphery and absent femoral pulse on both sides. An urgent computed tomography angiogram of the abdomen, pelvis and legs demonstrated complete occlusion of left common iliac artery and right common femoral artery with reformation of distal arteries [Figures 3A, B and C]. An emergency open bilateral ilio-femoral embolectomy was performed and a large thrombus removed from the left common iliac artery [Figure 4 A and B]. Unfortunately, the patient developed refractory sepsis with acute renal shut down and died after 10 days of admission. Figure 2: (A) Transesophageal echocardiography demonstrating disappearance of a large left atrial thrombus attached to a stuck mechanical valve after thrombolysis with reteplase. Note the bileaflet mechanical valve in closed position. (B) Transesophageal echocardiography ... Figure 3: Contrast-enhanced computed tomography (CT) scan in axial (A) view showing presence of contrast in the right common iliac artery (arrowheads) with absence of opacification of left common iliac artery in a patient with prosthetic valve thrombosis treated ... Figure 4: (A) Intra-operative image of a large thrombus protruding from left common iliac artery in a patient with prosthetic valve thrombosis treated with thrombolysis. (B) Image of a large thrombus explanted en bloc from left common iliac artery in the patient ... The incidence of left-sided prosthetic valve thrombosis (PVT) ranges from 0.5% to 0.8% per patient-year.1,2 The mortality of obstructive PVT is about 10% irrespective of the treatment strategy.1 The American College of Cardiology/American Heart Association (ACC/AHA) and American College of Chest Physicians guidelines recommend fibrinolytic therapy as first-line treatment for patients in good functional class with low thrombus burden ( 0.8cm2).3,4 Furthermore, in the following groups of patients surgery is advised, namely: 1) patients with large left atrial thrombus; 2) patients with any active bleeding or a history of intracranial bleeding; 3) patients with evidence of ischaemic stroke from 4 hours to six weeks, and 4) post-valve replacement within 4 days.1 The major complication of thrombolytic treatment for PVT is the risk of embolisation which occurs in 12–15% of the cases.3 A registry study demonstrated that thrombus size on TEE and a past history of stroke were independent predictors of complications as seen in this patient.2 Left atrial thrombi are also known to embolise at the time of, or shortly after a change in atrial rhythm.5 In this case, there was not only obstructive PVT, but it was associated with a large left atrial thrombus and hence surgery was the initial choice of treatment. However, the patient refused surgery and was thrombolysed with catastrophic embolism.