A 77-year-old woman with a history of hypertension, angioplasty of the anterior descending coronary artery, ischemic stroke, rheumatic mitral stenosis and atrial fibrillation, underwent gynecological surgery. Her warfarin therapy had been changed to enoxaparin, but at hospital discharge her international normalized ratio was below therapeutic levels, and so warfarin was restarted in addition to enoxaparin at prophylactic doses.

Two weeks after the procedure, she was admitted to the emergency department with chest discomfort. She was hypotensive and showed signs of peripheral hypoperfusion. The electrocardiogram revealed atrial fibrillation with complete atrioventricular block and ST-segment elevation in the inferior leads.

She was scheduled for primary angioplasty, which could not be performed by a radial approach due to the tortuosity of the subclavian artery (Figure 1A) and femoral access was hampered by absence of a pulse, and so a contrast-guided puncture was performed (Figure 1B and C). The external iliac artery was found to be occluded, but was passed using a hydrophilic guidewire. The mid segment of the right coronary artery was occluded by a thrombus (Figure 2A), which was removed by thrombectomy (Figure 2B).

Figure 1.

Left heart catheterization: (A) radial access made impossible due to the tortuosity of the subclavian artery, which prevented passage of the guidewire; (B) contrast-guided puncture of the left femoral artery; (C) catheterization by femoral access revealing a mobile thread-like structure (arrow), consistent with a thrombus.

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Figure 2.

Right coronary angiography: (A) occlusion of the mid segment of the right coronary artery; (B) reperfusion following aspiration of the thrombus.

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After reperfusion, signs of hypoperfusion persisted in the patient's lower limbs. In view of this finding, together with difficulty in femoral access, aortography was performed, which revealed thrombotic occlusion of the infrarenal abdominal aorta, extending to the iliac arteries (Figure 3). The echocardiogram showed a mass in the left atrium, consistent with a thrombus (Figure 4). Thromboembolectomy of the left iliac axis and femoro-femoral bypass were performed, but the patient developed multiple organ failure and died.

Figure 3.

Aortography: occlusion of the abdominal aorta by a large thrombus (arrow).

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Figure 4.

Transthoracic echocardiography, apical 4-chamber view, showing a hyperechoic and extremely mobile image (arrow) in the left atrium, consistent with a thrombus.

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This case illustrates a cardioembolic catastrophe with both coronary and systemic embolization and highlights the importance of appropriate perioperative anticoagulation.