Rare Presentation of Acute Lower Limb Ischemia: Saddle Aortic Embolus with Paraplegia - Case Report

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Almadwahi, Mohamed A. Alshujaa, Aref A. Al-Hashedi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3949717/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: This case report presents a unique and noteworthy occurrence of acute lower limb ischemia (ALI) accompanied by paraplegia in a 60-year-old male patient with a medical history of diabetes mellitus, hypertension, and ischemic heart disease. The novelty of this case lies in the rare association of ALI with paraplegia, which is an unusual and infrequently reported condition. Case presentation: A patient who underwent coronary artery bypass graft (CABG) surgery presented 12 days post-surgery with sudden onset right lower limb pain followed by paralysis in both lower limbs. Initially, Guillain-Barré syndrome (GBS) was suspected; however, further evaluation revealed occlusion in the abdominal aorta, common iliac artery, and external iliac arteries. The patient's management involved prompt diagnosis, administration of intravenous heparin, bilateral leg fasciotomy, and thrombectomy. These interventions resulted in the restoration of pulses and improvement in the patient's condition. Nonetheless, postoperative complications in the form of acute kidney injury were observed. Conclusions In conclusion, this case highlights the importance of maintaining a broad differential diagnosis when encountering rapidly progressing lower limb paralysis, especially in patients with vascular risk factors. Timely diagnosis and intervention in patients with acute limb ischemia can significantly impact patient outcomes. A multidisciplinary approach involving vascular surgeons, interventional radiologists, critical care specialists, and neurologists is crucial for optimizing patient outcomes in complex scenarios. Vascular Medicine Acute lower limb ischemia saddle aortic embolus paraplegia thrombectomy case report Figures Figure 1 Figure 2 Background Acute lower limb ischemia (ALI) is a severe vascular emergency with an annual incidence of 14 per 100,000 people. It is primarily caused by embolism (30%) or thrombosis (70%) and requires immediate diagnosis and treatment to prevent irreversible tissue damage and limb loss [ 1 ]. Although the most common etiology of ALI is thrombotic occlusion of peripheral arteries, rare presentations, such as saddle aortic embolus with associated paraplegia, pose unique diagnostic and management challenges. This case report highlights the rare presentation of ALI in a 60-year-old male patient and emphasizes the importance of a multidisciplinary approach in managing such complex scenarios. Case Presentation A 60-year-old male patient with a known history of diabetes mellitus type II (DM II), hypertension (HTN), and ischemic heart disease (IHD), on regular treatment in the form of oral antihyperglycemic, antihypertensive, and anti-ischemic medications. The patient was 12 days post coronary artery bypass grafting (CABG). He started to complain of a sudden onset of severe right lower limb pain lasting for half an hour, which rapidly progressed to the inability to move both lower limbs with complete loss of sensory function up to the inguinal region. The patient sought medical advice at a private Internal Medicine OPD clinic outside our hospital, where he was provisionally diagnosed with Guillain–Barré syndrome (GBS). Subsequently, the patient was sent to do a workup in the form of electromyography (EMG), nerve conduction studies (NCSs), and spinal computed tomography (CT) scans. Sixteen hours later, the patient started to develop cyanosis in both feet. A lower limb Doppler ultrasound revealed occlusion of the abdominal aorta and both common iliac arteries (CIA) and external iliac arteries (EIA), with tardus parvus flow observed from the common femoral artery (CFA) downward. The patient was transferred to our hospital 24 hours after the symptoms began. Upon arrival, the patient was conscious, oriented, and in stable condition, although experiencing slight dyspnea. Physical examination revealed mottling in both lower limbs, extending up to the distal thigh on the right side and below the knee on the left side. Both lower limbs were cold, and pulses were absent from both common femoral arteries (CFA) downward. There was no motor or sensory function observed below the inguinal area. Immediate action was taken, and the patient was administered intravenous heparin (5000 IU). Subsequently, he was admitted for surgery 26 h after the patient started to experience symptoms. A bilateral leg fasciotomy was performed, which revealed dusky-colored muscles with minimal dark-colored bleeding. Weak muscle contractions were observed upon electrocautery. Both CFAs were explored, and multiple large thrombi were extracted from the proximal and distal locations ( Fig. 1 ) ( Fig. 2 ) . Arterial repair was performed, followed by wound closure using a vacuum drain. The patient was then transferred to the intensive care unit (ICU) for postoperative observation and medical management. Pulse palpation was possible until both popliteal artery (PTA) levels were reached. The patient remained in the ICU for 48 h, during which his creatinine and potassium levels increased to 3.2 mg/dL and 5.2, respectively. After 12 h, he regained movement in his right lower limb, whereas the left lower limb did not improve. Subsequently, the creatinine and potassium levels improved, eventually returning to within the normal range. After 6 days, the patient was discharged in stable overall condition, and a good pulse was detected in both lower limbs. Motor and sensory functions were intact in the right lower limb. In comparison, the left lower limb exhibited only slight motor function in the thigh (grade 2), and the sensation was limited to painful stimuli from the mid-thigh. Discussion In this case, a 60-year-old male patient with a history of diabetes mellitus, hypertension, and ischemic heart disease presented with sudden severe lower limb pain and subsequent paralysis after coronary artery bypass grafting. Initially diagnosed with Guillain-Barré syndrome, further investigations revealed arterial thrombosis occluding the abdominal aorta and iliac arteries. Prompt administration of heparin was followed by surgical intervention, including bilateral leg fasciotomy and thrombus extraction. While the right lower limb showed improvement, the left lower limb had limited recovery. Strengths of the approach included prompt recognition and timely intervention on arrival to our hospital, while limitations included misdiagnosis on the initial presentation, delayed presentation to our hospital, and unilateral motor function improvement. The case presented here of a patient with saddle aortic embolus with paraplegia is a rare presentation of ALI and is notable for the rapid progression of symptoms and initial misdiagnosis. This patient's history of diabetes mellitus, hypertension, and ischemic heart disease, as well as recent coronary artery bypass grafting, would already place him at a higher risk for vascular events. The sudden onset of severe lower limb pain progressing to paralysis in both lower limbs is a classic presentation of ALI. It is often described as the "six Ps": pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (coolness). The initial provisional diagnosis of Guillain–Barré syndrome (GBS), a rare neurological disorder in which the body's immune system mistakenly attacks part of its peripheral nervous system, illustrates the challenges in diagnosing rare presentations of more common conditions. While GBS may present with rapidly progressing limb weakness, the suddenness of onset and severe pain experienced by this patient is more characteristic of vascular rather than neurological events [ 2 ]. Given the patient’s presenting symptoms and medical history, the differential diagnosis should include acute limb ischemia. A delay in correct diagnosis allows ischemia to progress, leading to cyanosis and mottling, indicating severe tissue hypoxia and impending necrosis. This delay may have contributed to the poorer recovery of the patient's left lower limb [ 3 ]. Occlusion of both the common iliac artery (CIA) and the external iliac artery (EIA) is indicative of a saddle embolus, a large embolus that straddles the bifurcation of an artery. In this case, the embolus likely originated from the heart, possibly related to the patient's recent CAB and history of DM [ 4 , 5 , 6 ]. The thrombi removed from the patient's common femoral arteries (CFAs) were likely secondary emboli that further occluded the distal circulation. Immediate anticoagulation with heparin and subsequent surgical intervention, including fasciotomy and thrombectomy, were appropriate and necessary steps to prevent irreversible tissue damage and possible limb loss. Despite these interventions, the patient's recovery was complicated by acute kidney injury, possibly due to emboli occluding renal arteries or to the systemic inflammatory response to acute ischemia. Furthermore, acute kidney injury is a known risk factor following cardiac catheterization and elective coronary artery bypass surgery [ 7 ]. The patient's partial recovery of motor and sensory function in the left lower limb indicated the severity of the ischemic injury. The fact that sensation was limited to painful stimuli from the mid-thigh suggested that nerve function was more severely affected in the distal versus proximal portions of the limb, consistent with the ischemic insult being more severe distally due to the occlusion of the CFAs. The mechanism underlying the paraplegia observed in this patient can be attributed to occlusion of the lumbar and sacral arteries, which originate from the abdominal aorta and provide blood to the spinal cord. As described in a case report titled "Saddle embolism of the aorta with sudden paraplegia" by AS Olearchyk, a saddle embolus lodged at the level of L4 can effectively cut off blood supply to the lower spinal cord, resulting in acute ischemia and subsequent paraplegia [ 8 ]. Another case report titled "Recovery from paraplegia following aortic saddle embolism. A case report by Chandrashekar et al. described a similar patient who experienced a sudden onset of paraplegia due to a saddle embolus. The patient's paraplegia resolved over 2 months [ 9 ]. The pathophysiology of acute lower limb ischemia involves complex cellular and molecular mechanisms. When arterial blood flow is abruptly removed, as in the case of a saddle embolus, the affected tissues are subjected to ischemia, leading to a state of hypoxia. This triggers a cascade of events, including the production of reactive oxygen species, activation of inflammatory pathways, and cell death. If the ischemia is not promptly reversed, irreversible tissue damage and necrosis can occur, leading to clinical manifestations of acute limb ischemia, including severe pain, pallor, pulselessness, and paralysis [ 10 ]. Moreover, paraplegia can also be attributed to a reduction in perfusion pressure, as observed in cases of hypotensive infarction of the spinal cord [ 11 ]. The documented correlation between acute aortic occlusion and paraplegia emphasizes the critical importance of recognizing and addressing such acute ischemic events to prevent devastating neurological complications. The successful management of acute limb ischemia, involving intravenous heparin administration, bilateral leg fasciotomy, and thrombectomy, aligns with the standard approach for treating ALI [ 11 ]. However, the development of residual motor and sensory deficits in the left lower limb underscores the importance of early intervention in preventing limb loss and improving overall outcomes in patients with ALI. Conclusion In conclusion, this case highlights the importance of maintaining a broad differential diagnosis when encountering rapidly progressing lower limb paralysis, especially in patients with vascular risk factors. Timely diagnosis and intervention in patients with acute limb ischemia can significantly impact patient outcomes. A multidisciplinary approach involving vascular surgeons, interventional radiologists, critical care specialists, and neurologists is crucial for optimizing patient outcomes in complex scenarios. Declarations Ethics Approval and Consent to Participate This study was approved by the Ethics Committee of the Faculty of Medicine and Health Sciences, Sana’a University, and Al-Thawra Hospital Academy. Consent for publication was also obtained from the patient. Consent for Publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of supporting data The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The author declares that he has no competing interests associated with this article. Financial Support The Author declares that no financial support was received. Authors' contributions Nabeel Y. Almadwahi contributed to the conception, Mohamed A. Alshujaa to the design, Aref A. Al-Hashedi to data interpretation, and Haitham M. Jowah to drafting or substantive revision. All authors approved the submitted version, taking personal accountability for their contributions and ensuring thorough investigation and resolution of any accuracy or integrity concerns. For correspondence: Haitham M.Jowah Acknowledgments The authors thank the Administration of Thawar Modern General Hospital and the patient for permitting the publication of this case report. References Björck M., Earnshaw J., Acosta S., Gonçalves F., Cochennec F., Debus E. et al.. Editor's choice – european society for vascular surgery (esvs) 2020 clinical practice guidelines on the management of acute limb ischaemia. European Journal of Vascular and Endovascular Surgery 2020;59(2):173–218. https://doi.org/10.1016/j.ejvs.2019.09.006 Dourmishev L., Nikolova K., & Miteva L.. Cutaneous manifestations of aortoiliac occlusive disease: two cases and review of the literature. Folia Medica 2022;64(4):682–687. https://doi.org/10.3897/folmed.64.e64221 Islam S., Deka N., & Hussain Z.. Role of doppler ultrasound in assessing the severity of peripheral arterial diseases of the lower limb. Journal of Medical Ultrasound 2021;29(4):277. https://doi.org/10.4103/jmu.jmu_137_20 Rango P., Farchioni L., Fiorucci B., & Lenti M.. Diabetes and abdominal aortic aneurysms. European Journal of Vascular and Endovascular Surgery 2014;47(3):243–261. https://doi.org/10.1016/j.ejvs.2013.12.007 Ali I., Shokri H., & Jawad M.. Assessment of carotid artery stenosis and lower limb peripheral ischemia before coronary artery bypass grafting operations: a non-randomized clinical trial. Journal of Cardiothoracic Surgery 2020;15(1). https://doi.org/10.1186/s13019-020-01340-7 Mehta R., Honeycutt E., Patel U., Lopes R., Williams J., Shaw L. et al.. Relationship of the time interval between cardiac catheterization and elective coronary artery bypass surgery with postprocedural acute kidney injury. Circulation 2011;124(11_suppl_1). https://doi.org/10.1161/circulationaha.110.011700 Crawford E., Crawford J., Safi H., Coselli J., Hess K., Brooks B. et al.. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. Journal of Vascular Surgery 1986;3(3):389–404. https://doi.org/10.1067/mva.1986.avs0030389 Olearchyk AS. Saddle embolism of the aorta with sudden paraplegia. Can J Surg. 2004;47(6):472–473. Chandrashekar G., Acharya P., Rao J., Kumar R., & Nayak G.. Recovery from paraplegia following aortic saddle embolism. case report. Spinal Cord 1994;32(2):112–116. https://doi.org/10.1038/sc.1994.20 Hollier L.. Pathophysiology of spinal cord ischemia. Vascular Surgery 2005:257–267. https://doi.org/10.1002/9780470987094.ch25 Singh U., Silver J., & Welply N.. Hypotensive infarction of the spinal cord. Spinal Cord 1994;32(5):314–322. https://doi.org/10.1038/sc.1994.54 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3949717","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":272336989,"identity":"835bab5e-c8d2-492d-ab9f-df465f246e22","order_by":0,"name":"Nabeel Y. Almadwahi","email":"","orcid":"","institution":"Department of Vascular Surgery, Al-Thawra Modern General Hospital, Faculty of Medicine, Sana’a University, Sana’a City, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Nabeel","middleName":"Y.","lastName":"Almadwahi","suffix":""},{"id":272336990,"identity":"94cd6c75-6981-4208-86f9-e10775a314e0","order_by":1,"name":"Mohamed A. 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It is primarily caused by embolism (30%) or thrombosis (70%) and requires immediate diagnosis and treatment to prevent irreversible tissue damage and limb loss [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although the most common etiology of ALI is thrombotic occlusion of peripheral arteries, rare presentations, such as saddle aortic embolus with associated paraplegia, pose unique diagnostic and management challenges. This case report highlights the rare presentation of ALI in a 60-year-old male patient and emphasizes the importance of a multidisciplinary approach in managing such complex scenarios.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 60-year-old male patient with a known history of diabetes mellitus type II (DM II), hypertension (HTN), and ischemic heart disease (IHD), on regular treatment in the form of oral antihyperglycemic, antihypertensive, and anti-ischemic medications. The patient was 12 days post coronary artery bypass grafting (CABG). He started to complain of a sudden onset of severe right lower limb pain lasting for half an hour, which rapidly progressed to the inability to move both lower limbs with complete loss of sensory function up to the inguinal region.\u003c/p\u003e \u003cp\u003eThe patient sought medical advice at a private Internal Medicine OPD clinic outside our hospital, where he was provisionally diagnosed with Guillain\u0026ndash;Barr\u0026eacute; syndrome (GBS). Subsequently, the patient was sent to do a workup in the form of electromyography (EMG), nerve conduction studies (NCSs), and spinal computed tomography (CT) scans.\u003c/p\u003e \u003cp\u003eSixteen hours later, the patient started to develop cyanosis in both feet. A lower limb Doppler ultrasound revealed occlusion of the abdominal aorta and both common iliac arteries (CIA) and external iliac arteries (EIA), with tardus parvus flow observed from the common femoral artery (CFA) downward.\u003c/p\u003e \u003cp\u003eThe patient was transferred to our hospital 24 hours after the symptoms began. Upon arrival, the patient was conscious, oriented, and in stable condition, although experiencing slight dyspnea. Physical examination revealed mottling in both lower limbs, extending up to the distal thigh on the right side and below the knee on the left side. Both lower limbs were cold, and pulses were absent from both common femoral arteries (CFA) downward. There was no motor or sensory function observed below the inguinal area.\u003c/p\u003e \u003cp\u003eImmediate action was taken, and the patient was administered intravenous heparin (5000 IU). Subsequently, he was admitted for surgery 26 h after the patient started to experience symptoms. A bilateral leg fasciotomy was performed, which revealed dusky-colored muscles with minimal dark-colored bleeding. Weak muscle contractions were observed upon electrocautery. Both CFAs were explored, and multiple large thrombi were extracted from the proximal and distal locations \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e) (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Arterial repair was performed, followed by wound closure using a vacuum drain. The patient was then transferred to the intensive care unit (ICU) for postoperative observation and medical management. Pulse palpation was possible until both popliteal artery (PTA) levels were reached.\u003c/p\u003e \u003cp\u003eThe patient remained in the ICU for 48 h, during which his creatinine and potassium levels increased to 3.2 mg/dL and 5.2, respectively. After 12 h, he regained movement in his right lower limb, whereas the left lower limb did not improve. Subsequently, the creatinine and potassium levels improved, eventually returning to within the normal range. After 6 days, the patient was discharged in stable overall condition, and a good pulse was detected in both lower limbs. Motor and sensory functions were intact in the right lower limb. In comparison, the left lower limb exhibited only slight motor function in the thigh (grade 2), and the sensation was limited to painful stimuli from the mid-thigh.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this case, a 60-year-old male patient with a history of diabetes mellitus, hypertension, and ischemic heart disease presented with sudden severe lower limb pain and subsequent paralysis after coronary artery bypass grafting. Initially diagnosed with Guillain-Barr\u0026eacute; syndrome, further investigations revealed arterial thrombosis occluding the abdominal aorta and iliac arteries. Prompt administration of heparin was followed by surgical intervention, including bilateral leg fasciotomy and thrombus extraction. While the right lower limb showed improvement, the left lower limb had limited recovery. Strengths of the approach included prompt recognition and timely intervention on arrival to our hospital, while limitations included misdiagnosis on the initial presentation, delayed presentation to our hospital, and unilateral motor function improvement.\u003c/p\u003e \u003cp\u003eThe case presented here of a patient with saddle aortic embolus with paraplegia is a rare presentation of ALI and is notable for the rapid progression of symptoms and initial misdiagnosis.\u003c/p\u003e \u003cp\u003eThis patient's history of diabetes mellitus, hypertension, and ischemic heart disease, as well as recent coronary artery bypass grafting, would already place him at a higher risk for vascular events. The sudden onset of severe lower limb pain progressing to paralysis in both lower limbs is a classic presentation of ALI. It is often described as the \"six Ps\": pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (coolness).\u003c/p\u003e \u003cp\u003eThe initial provisional diagnosis of Guillain\u0026ndash;Barr\u0026eacute; syndrome (GBS), a rare neurological disorder in which the body's immune system mistakenly attacks part of its peripheral nervous system, illustrates the challenges in diagnosing rare presentations of more common conditions. While GBS may present with rapidly progressing limb weakness, the suddenness of onset and severe pain experienced by this patient is more characteristic of vascular rather than neurological events [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the patient\u0026rsquo;s presenting symptoms and medical history, the differential diagnosis should include acute limb ischemia. A delay in correct diagnosis allows ischemia to progress, leading to cyanosis and mottling, indicating severe tissue hypoxia and impending necrosis. This delay may have contributed to the poorer recovery of the patient's left lower limb [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOcclusion of both the common iliac artery (CIA) and the external iliac artery (EIA) is indicative of a saddle embolus, a large embolus that straddles the bifurcation of an artery. In this case, the embolus likely originated from the heart, possibly related to the patient's recent CAB and history of DM [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The thrombi removed from the patient's common femoral arteries (CFAs) were likely secondary emboli that further occluded the distal circulation.\u003c/p\u003e \u003cp\u003eImmediate anticoagulation with heparin and subsequent surgical intervention, including fasciotomy and thrombectomy, were appropriate and necessary steps to prevent irreversible tissue damage and possible limb loss. Despite these interventions, the patient's recovery was complicated by acute kidney injury, possibly due to emboli occluding renal arteries or to the systemic inflammatory response to acute ischemia. Furthermore, acute kidney injury is a known risk factor following cardiac catheterization and elective coronary artery bypass surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patient's partial recovery of motor and sensory function in the left lower limb indicated the severity of the ischemic injury. The fact that sensation was limited to painful stimuli from the mid-thigh suggested that nerve function was more severely affected in the distal versus proximal portions of the limb, consistent with the ischemic insult being more severe distally due to the occlusion of the CFAs.\u003c/p\u003e \u003cp\u003eThe mechanism underlying the paraplegia observed in this patient can be attributed to occlusion of the lumbar and sacral arteries, which originate from the abdominal aorta and provide blood to the spinal cord. As described in a case report titled \"Saddle embolism of the aorta with sudden paraplegia\" by AS Olearchyk, a saddle embolus lodged at the level of L4 can effectively cut off blood supply to the lower spinal cord, resulting in acute ischemia and subsequent paraplegia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother case report titled \"Recovery from paraplegia following aortic saddle embolism. A case report by Chandrashekar et al. described a similar patient who experienced a sudden onset of paraplegia due to a saddle embolus. The patient's paraplegia resolved over 2 months [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathophysiology of acute lower limb ischemia involves complex cellular and molecular mechanisms. When arterial blood flow is abruptly removed, as in the case of a saddle embolus, the affected tissues are subjected to ischemia, leading to a state of hypoxia. This triggers a cascade of events, including the production of reactive oxygen species, activation of inflammatory pathways, and cell death. If the ischemia is not promptly reversed, irreversible tissue damage and necrosis can occur, leading to clinical manifestations of acute limb ischemia, including severe pain, pallor, pulselessness, and paralysis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, paraplegia can also be attributed to a reduction in perfusion pressure, as observed in cases of hypotensive infarction of the spinal cord [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The documented correlation between acute aortic occlusion and paraplegia emphasizes the critical importance of recognizing and addressing such acute ischemic events to prevent devastating neurological complications.\u003c/p\u003e \u003cp\u003eThe successful management of acute limb ischemia, involving intravenous heparin administration, bilateral leg fasciotomy, and thrombectomy, aligns with the standard approach for treating ALI [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the development of residual motor and sensory deficits in the left lower limb underscores the importance of early intervention in preventing limb loss and improving overall outcomes in patients with ALI.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this case highlights the importance of maintaining a broad differential diagnosis when encountering rapidly progressing lower limb paralysis, especially in patients with vascular risk factors. Timely diagnosis and intervention in patients with acute limb ischemia can significantly impact patient outcomes. A multidisciplinary approach involving vascular surgeons, interventional radiologists, critical care specialists, and neurologists is crucial for optimizing patient outcomes in complex scenarios.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Faculty of Medicine and Health Sciences, Sana\u0026rsquo;a University, and Al-Thawra Hospital Academy. Consent for publication was also obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of supporting data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that he has no competing interests associated with this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Support\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Author declares that no financial support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNabeel Y. Almadwahi contributed to the conception, Mohamed A. Alshujaa to the design, Aref A. Al-Hashedi to data interpretation, and Haitham M. Jowah to drafting or substantive revision. All authors approved the submitted version, taking personal accountability for their contributions and ensuring thorough investigation and resolution of any accuracy or integrity concerns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFor correspondence:\u003c/strong\u003e Haitham M.Jowah\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Administration of Thawar Modern General Hospital and the patient for permitting the publication of this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBj\u0026ouml;rck M., Earnshaw J., Acosta S., Gon\u0026ccedil;alves F., Cochennec F., Debus E. et al.. 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European Journal of Vascular and Endovascular Surgery 2014;47(3):243\u0026ndash;261. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejvs.2013.12.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ejvs.2013.12.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli I., Shokri H., \u0026amp; Jawad M.. Assessment of carotid artery stenosis and lower limb peripheral ischemia before coronary artery bypass grafting operations: a non-randomized clinical trial. Journal of Cardiothoracic Surgery 2020;15(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13019-020-01340-7\u003c/span\u003e\u003cspan address=\"10.1186/s13019-020-01340-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehta R., Honeycutt E., Patel U., Lopes R., Williams J., Shaw L. et al.. Relationship of the time interval between cardiac catheterization and elective coronary artery bypass surgery with postprocedural acute kidney injury. Circulation 2011;124(11_suppl_1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1161/circulationaha.110.011700\u003c/span\u003e\u003cspan address=\"10.1161/circulationaha.110.011700\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford E., Crawford J., Safi H., Coselli J., Hess K., Brooks B. et al.. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. Journal of Vascular Surgery 1986;3(3):389\u0026ndash;404. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1067/mva.1986.avs0030389\u003c/span\u003e\u003cspan address=\"10.1067/mva.1986.avs0030389\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlearchyk AS. Saddle embolism of the aorta with sudden paraplegia. Can J Surg. 2004;47(6):472\u0026ndash;473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandrashekar G., Acharya P., Rao J., Kumar R., \u0026amp; Nayak G.. Recovery from paraplegia following aortic saddle embolism. case report. Spinal Cord 1994;32(2):112\u0026ndash;116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/sc.1994.20\u003c/span\u003e\u003cspan address=\"10.1038/sc.1994.20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHollier L.. Pathophysiology of spinal cord ischemia. Vascular Surgery 2005:257\u0026ndash;267. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/9780470987094.ch25\u003c/span\u003e\u003cspan address=\"10.1002/9780470987094.ch25\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh U., Silver J., \u0026amp; Welply N.. Hypotensive infarction of the spinal cord. Spinal Cord 1994;32(5):314\u0026ndash;322. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/sc.1994.54\u003c/span\u003e\u003cspan address=\"10.1038/sc.1994.54\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sana'a University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute lower limb ischemia, saddle aortic embolus, paraplegia, thrombectomy, case report","lastPublishedDoi":"10.21203/rs.3.rs-3949717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3949717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThis case report presents a unique and noteworthy occurrence of acute lower limb ischemia (ALI) accompanied by paraplegia in a 60-year-old male patient with a medical history of diabetes mellitus, hypertension, and ischemic heart disease. The novelty of this case lies in the rare association of ALI with paraplegia, which is an unusual and infrequently reported condition.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA patient who underwent coronary artery bypass graft (CABG) surgery presented 12 days post-surgery with sudden onset right lower limb pain followed by paralysis in both lower limbs. Initially, Guillain-Barr\u0026eacute; syndrome (GBS) was suspected; however, further evaluation revealed occlusion in the abdominal aorta, common iliac artery, and external iliac arteries. The patient's management involved prompt diagnosis, administration of intravenous heparin, bilateral leg fasciotomy, and thrombectomy. These interventions resulted in the restoration of pulses and improvement in the patient's condition. Nonetheless, postoperative complications in the form of acute kidney injury were observed.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn conclusion, this case highlights the importance of maintaining a broad differential diagnosis when encountering rapidly progressing lower limb paralysis, especially in patients with vascular risk factors. Timely diagnosis and intervention in patients with acute limb ischemia can significantly impact patient outcomes. A multidisciplinary approach involving vascular surgeons, interventional radiologists, critical care specialists, and neurologists is crucial for optimizing patient outcomes in complex scenarios.\u003c/p\u003e","manuscriptTitle":"Rare Presentation of Acute Lower Limb Ischemia: Saddle Aortic Embolus with Paraplegia - Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-13 18:51:03","doi":"10.21203/rs.3.rs-3949717/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1","owner":[],"postedDate":"February 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28703084,"name":"Vascular Medicine"}],"tags":[],"updatedAt":"2024-02-13T18:51:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-13 18:51:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3949717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3949717","identity":"rs-3949717","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}