Complications of reperfusion in acute aortic artery occlusion following saddle embolization originating from an atrial myxoma.

A 58-year-old man presented to the hospital with an 8-hour history of acute-onset bilateral lower limb ischemia. A large saddle embolus had occluded the aorta and could not be removed by balloon endarterectomy through the femoral arteries. Successful open aortic and femoral thromboembolectomy followed by extensive fasciotomies was accompanied by severe reperfusion injury. Life-threatening hyperkalemia was associated with three episodes of intraoperative ventricular fibrillation and ventricular tachycardia requiring cardiac massage and defibrillation. A dextrose-insulin-bicarbonate infusion was required to correct the hyperkalemia. Rhabdomyolysis developed at 24 hours, causing marked myoglobinuria and acute renal failure, which required hemofiltration. Histology of the recovered embolus confirmed an atrial myxoma, and when the patient had fully recovered, open cardiac surgery was carried out to resect the tiny stump of residual myxoma. Rhabdomyolysis associated with a myxomatous saddle embolus has not been previously reported. This case highlights the need for pre- and perioperative measures to be taken to overcome hyperkalemia and acute renal failure when revascularizing acute, massive, prolonged ischemia of the lower body.