CASE REPORT
This is a case of year old female presenting to PGIMER emergency with complaints of acute severe limb pain in both lower limbs and right upper limb for past 6 hours. Patient was evaluated clinically and acute limb ischemia was suspected for which patient underwent emergency CT Angiography of abdominal aorta till bilateral lower limbs and bilateral upper limbs. CT Angiography revealed hypo dense filling defect in the infra renal abdominal aorta extending till bilateral common iliac arteries and extending till right brachial artery till its bifurcation (Figure 1 Figure 2 )
Patient was started on heparinisation as per Acute Limb Ischemia protocol with serial aPTT monitoring and aPTT was kept in the range of 45-70. Following initial stabilisation, patient underwent 2D-ECHO, which revealed 41* mm mass in Left Atrium attached to intra-artrial septum, prolapsing in LV cavity causing obstruction to flow of mitral valve resulting in Moderate Mitral regurgitation.( Figure 3 Figure 4 )
Patient was planned for Emergency LA Myxoma excision under Cardio pulmonary bypass (CPB) with embolectomy of Right Brachial Artery and abdominal aorta, bilateral Common Iliac artery and bilateral femoral artery (superficial and deep branches). Although patient did not complain of headache, vomiting, loss of consciousness or ENT bleed, Preoperative NCCT head was done for risk analysis of heparinisation of acute limb ischemia and subsequent heparinisation required during CPB, which revealed acute bleed in right side fronto-temporal region. Considering the risks of systemic heparinisation during CPB with increase in intra cranial bleed causing life threatening complications, the plan was changed. Patient was then taken up for surgery and fogartisation was done via bilateral femoral approach and a large myxomatous tissue was removed. Fogartisation was also done from right brachial artery and similar myxomatous tissue was extracted (Figure 5 Figure 6 )Post-operative patient had pulses in both lower limb Popliteal artery, femoral artery, ATA,PTA,DPA and in Right brachial artery and right radial and ulnar artery. Patient was kept on low dose of heparin infusion for 24 hours post-surgery. She has been planned for definitive LA Myxoma excision 4 weeks later.