Mx of free-floating thrombus in arch of aorta in UL ischemia
The present case has been reported in the Indian Journal of Vascular and Endovascular Surgery.

A 42-year-old male was admitted in the emergency with left upper limb ischemia. He was complaining of rest pain and had discoloration of fingertips, for 1 day. His left upper limb was cold, numb, with discoloration of fingertips, and grossly restricted movements. None of the pulses were felt in the left upper limb.

Urgent duplex scan revealed triphasic flow in the first part of subclavian and no flow in remaining subclavian and distal arterial system, suggestive of thrombosis. As his serum creatinine was 1.5, an angiography was kept on hold. His initial ECHO ruled out any cardiac source; however, transesophageal echocardiography (TEE) was not done at the first go. In view of his pain and advanced ischemia, he was subjected to emergency left transbrachial embolectomy.

Fresh and old thrombus was extracted and blood circulation was restored. Pulses appeared after the procedure, and the hand was warm. In view of good recovery, intraoperative DSA was not considered and even thrombolysis was not thought of. He was started on medical management, which consisted of adequate anticoagulation, antiplatelets, and vasodilator. However, pulses disappeared after 12 h. Reexploration and thrombectomy was attempted. Pulses again appeared and then disappeared after few hours.

In view of repeated thrombosis and distal disease, he was started on prostaglandin infusion along with anticoagulation, antiplatelets, and vasodilator. The patient was further evaluated to find out the origin of the thrombus since now his serum creatinine was within normal range after good hydration. His computed tomography (CT) angiography revealed a large floating thrombus of about 6 cm × 4 cm in the arch of the aorta with total occlusion of axillary, brachial, and distal vessels. His cardiac assessment was normal.

All the relevant hematological and biochemical reports were within normal limits. The diagnosis of hypercoagulation state was excluded by the negative complete coagulation profile and lack of previous unexplained arterial or venous thrombosis in his or his family members. His vasculitis work-up was also negative.

The surgeons planned for 4-week aggressive medical management followed by surgery. The patient was started on continuous heparin infusion 1000 units/h initially with the aim of maintaining activated partial thromboplastin time levels double the normal and then shifted her to intermittent intravenous therapy alone with oral anticoagulation. He was discharged on oral anticoagulant, once attaining his international normalized ratio (INR) between 2 and 4.

Clinically, his upper limb symptoms improved, had minimum pain at discharge, and he was able to hold objects. After 4 weeks, the transesophageal echocardiogram was repeated, which revealed significant reduction of the thrombus in the arch of the aorta. He is now on oral anticoagulant and maintaining his INR in between 2 and 4. After 3 months of his anticoagulation therapy, CT angiogram of the neck demonstrated complete resolution of the thrombus from the arch of the aorta.

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