AORTIC-ARCH AS A SOURCE OF PERIPHERAL ART ERIAL EMBOLI

History and clinical findings: On the day before admission a 68-year-o ld woman had an acute episode of incomplete ischaemia of the left lowe r arm. She had no known heart disease and her general condition was un changed. There were no palpable pulses in the cold and pale lower arm. Sensory and motor functions of the left hand were slightly impaired. Arterial embolisation was suspected. Investigations: The blood picture was normal, erythrocyte sedimentation rate 20/50 mm, C-reactive prote in elevated to 7.0 mg/l. There was no evidence of clotting abnormality . The resting ECG showed normal sinus rhythm. Doppler ultrasound gave a systolic pressure of 80 mm Hg over the radial artery and 50 mm Hg ov er the ulnar artery, with a systemic systolic pressure of 140 mm Hg. N o intracardiac thrombi were seen on echocardiography. Transoesophageal echocardiography revealed a 2 x 3 cm hypermobile mass in the distal a ortic arch, most likely a thrombus as the source of the embolus. Contr ast computed tomography and digital subtraction angiography also demon strated the mass. Treatment and course: At first heparin (bolus of 500 0 IU, then 1000 IU/h) was infused. One day after the diagnosis had bee n established thrombectomy of the aortic arch and embolectomy of the l eft brachial artery were performed without complication. The patient w as discharged on the 15th postoperative day on a maintenance dose of p henprocoumon. Histological examination of the surgical specimen from t he aorta showed a separating thrombus on an ulcerating atherosclerotic plaque. Conclusion: The importance of the thoracic aorta as a source of emboli is often underestimated. Transoesophageal echocardiography i s a reliable method to demonstrate aortic thrombi.