Answer of March 2006

Clinical History:

A 48 year old lady with chronic rheumatic heart disease (mainly mitral stenosis) and in atrial fibrillation. She had 2 episodes of pain and numbness in the calf and feet. The first episode was after stopping warfarin for a few days for dental extraction. The symptoms improved later but did not completely subside.

Diagnosis:

Arterial Thrombo-embolism

Discussion:

The patient has rheumatic mitral stenosis. This is commonly associated with enlarged L atrium which can predispose to L atrial clot. The patient was put on warfarin for this reason. With L heart thrombus, there is chance of systemic thrombo-embolism.

CT angiogram shows bilateral blocked popliteal arteries while the common femoral and superficial femoral arteries are normal. Collateral formation at level of knee joint (from genicular arteries) are re-constituting the main calf arteries. This suggests chronic and probably recurrent episodes of embolism with no critical acute ischaemia.