Case Presentation: A 64-year-old woman with a history of right kidney transplant and Crohn’s disease in remission presented to the emergency department with five days of severe abdominal pain. Her pain was accompanied by nausea, vomiting, and chills. Physical examination was notable for an abdomen that was distended and diffusely tender to palpation, but not peritonitic. Initial evaluation revealed hypotension, elevated lactate, leukocytosis, and elevated creatinine. A CTA abdomen/pelvis identified wedge-shaped infarcts in the patient’s transplanted kidney as well as her spleen concerning for infarcts due to hypoperfusion. She was admitted, anticoagulated with a heparin drip, and placed on broad spectrum antibiotics for sepsis of unknown source. On hospital day 2, the patient developed persistent hemodynamic instability which required placement of a central venous catheter and admission to the SICU. A repeat CTA abdomen/pelvis revealed no mesenteric ischemia. By hospital day 3, the patient’s blood pressure stabilized, and she was transferred back to the general medicine floor. Although the patient’s abdominal pain gradually improved, on hospital day 7, she experienced sudden onset of left upper extremity pain, numbness, and weakness. Her left upper extremity blood pressures and pulse were undetectable. Right upper extremity systolic blood pressures were above 200 mmHg. A CTA of the chest and left upper extremity showed plaque-like protruding filling defects in the aortic arch and proximal descending thoracic aorta with a left brachial artery occlusion. The patient was immediately taken to the OR for a left brachial artery cutdown and left brachial artery thromboembolectomy. A transesophageal echocardiogram (TEE) on hospital day 9 demonstrated a normal left ventricular ejection fraction, but revealed multiple large mobile hyperechoic masses in the transverse and descending aorta. The patient was started on warfarin in addition to her heparin drip. Her postoperative course was uncomplicated, and she was discharged on hospital day 12.

Discussion: This case demonstrates multiple aortic thrombi as a potential multifactorial source of renal infarct, abdominal pain, and brachial artery occlusion. Unfractionated and low-molecular weight heparins and direct oral anticoagulants are commonly used for venous thromboembolism prophylaxis in hospitalized patients. Anticoagulation agents, however, only limit propagation, and therefore do not lyse pre-existing thrombi. Arterial embolism and thrombosis are known causes of acute mesenteric ischemia. Although multiple abdominal CTA scans showed no mesenteric ischemia in this patient, it is likely that micro-emboli too small for detection were the source of the patient’s abdominal pain. Since both renal transplant and inflammatory bowel disease induce a hypercoagulable state, the patient was at increased risk of developing a thrombus.

Conclusions: Clinicians should consider performing a CTA of the chest in addition to an abdominal CTA to rule out aortic involvement when localizing an unknown source of abdominal pain and renal and/or splenic infarct.

IMAGE 1: Figure 1: CT w/ IV contrast showing R Renal infarct

IMAGE 2: Figure 2a, 2b: CT LUE w/ IV contrast (left) showing filling defect likely occlusive thrombus within the left brachial artery. CT w/ IV contrast (right) showing filling defect adjacent to L subclavian with multiple filling defects distally. Calcified thromboembolism defect likely etiology of occlusive embolus of L brachial artery