Case Report: A successful percutaneous revascularization of bilateral acute limb ischemia caused by an aortic saddle embolism in a patient with mitral stenosis.

BACKGROUND

An aortic saddle embolism (ASE) is an uncommon condition involving sudden aortoiliac occlusion where emboli lodge at the aortic bifurcation, causing bilateral lower-extremity arterial occlusion. This can lead to ischemia, potential amputation, or even death due to severe reperfusion injury and multiple organ failure. Prompt and effective restoration of arterial flow is crucial to prevent irreversible tissue infarction and to preserve limb viability. Various revascularization techniques, including endovascular and surgical thrombectomy, can be employed to manage this condition.

CASE ILLUSTRATION: A 40-year-old woman presented with severe pain and numbness in both legs and a bluish tinge in both toes. An electrocardiogram showed atrial fibrillation, and transthoracic echocardiography revealed severe mitral stenosis. The patient underwent percutaneous angiography, which revealed total occlusion at the distal abdominal aorta, followed by percutaneous mechanical thrombectomy or percutaneous thromboaspiration, for which a vacuum-assisted device with conventional wall suction was used, which restored flow to the left lower extremity. Subsequently, the patient received heparin therapy, pain management, and anti-inflammatory treatment. A second percutaneous thromboaspiration with additional balloon angioplasty was performed several days later, which successfully restored flow to the right distal extremity. A duplex ultrasound evaluation after the second percutaneous procedure showed normal arterial and venous blood flow in both lower extremities. The patient experienced no significant complications and recovered fully. One year later, the patient underwent mitral valve replacement with good outcomes and no complications.

CONCLUSION

A modified wall-suction thromboaspiration may represent a feasible bailout or resource-adapted option for bilateral acute limb ischemia caused by an aortic saddle embolism when dedicated thrombectomy devices are unavailable, but the safety, blood loss risk, and reproducibility of this procedure require further evaluation.