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Aortic saddle embolism following pneumonectomy for synovial sarcoma of lung

A 30-year-old young man presented with a 4-month history of pain in the left side of his chest, breathlessness, and a cough without haemoptysis. The patient had significant weight loss (7 kg in the last 4 months). He was evaluated at other hospital and referred to our centre with a diagnosis of left-sided pulmonary malignancy. Computed tomography of the chest showed a heterogeneously enhancing soft tissue mass in the upper lobe of the left lung, measuring 11.2 × 10.8 × 15.8-cm with areas of necrosis inside the mass (Fig. 1a). The lesion was abutting the intercostal muscles anterolaterally and pericardium medially. Compression of left upper lobe bronchus was present, resulting in collapse of the underlying lung segments with a moderate pleural effusion but no involvement of any vascular structure was seen. His positron emission tomography scan showed an intensely fluorodeoxyglucose avid mass in upper lobe (standardized uptake value of 7.3) with non-fluorodeoxyglucose avid pleural effusion and non-fluorodeoxyglucose avid subcentimetric lymph nodes (Fig. 1b). Transthoracic echocardiography evaluation showed normal cardiac chambers and valves with an ejection fraction of 55–60%. He underwent left side posterolateral thoracotomy by fifth intercostal space; the lung tumour was found to be adherent to the intercostal muscles, left diaphragm and hilar structures. He was thus managed by pneumonectomy. On the first post-operative day, patient was initially doing well but developed acute onset pain in both lower limbs with absent bilateral femoral and distal pulses. Computed tomography angiogram showed saddle thrombus at aortic bifurcation (Fig. 2). The patient was promptly taken to the operation room for retrograde aortoiliac thrombectomy through bilateral femoral arteriotomies. Under monitored anaesthesia care with local anaesthesia, bilateral femoral thromboembolectomy was performed and thrombus mixed with whitish tumour material was retrieved from both femoral arteries by retrograde thrombectomy (Fig. 3). Bilaterally, femoral and pedal pulses were restored after thrombectomy. The patient did not develop compartment syndrome in calves and was discharged on post-operative day 12. The patient was given therapeutic anticoagulation with unfractionated heparin post-operatively for 5 days, followed by antiplatelets for 6 months. The patient’s lung tumour histopathology showed synovial cell sarcoma (Fig. S1) as was the tumour removed from the femoral arteries. The patient was treated with adjuvant chemotherapy in the post-operative period for advanced disease and is recurrence free at 16 months of follow-up. Arterial embolism is a fairly common event in the axial limb vessels, comprising the major manifestation of embolic disease, followed by cerebrovascular and visceral ischaemia. The majority of emboli have a cardiac origin, but approximately 10–20% have a non-cardiac origin which may be from atheromatous plaques in diseased aortoiliac tree, loose aneurysmal thrombus, foreign bodies or air. Acute limb ischaemia in malignancy is attributed mainly to malignancy related hypercoagulopathy, or embolus from valvular