Embolism from mural thrombus in the thoracic aorta.

Mural thrombus in the internal carotid artery is a source of emboli to the retinal and cerebral arteries, causing transient or permanent blindness and hemiplegia (Gunning et al., 1946b); thrombi in subclavian arteries damaged by cervical ribs form emboli which lodge in the digital arteries, inducing ischaemia of the fingers and thickened intima (Gunning et al., 1964a).Emboli from mural thrombi in the popliteal artery have been implicated in gangrene of the great toe (Ross, 1936).Mural thrombi on plaques of nodular arteriosclerosis are common in the abdominal aorta, but the frequency with which they form emboli to the abdominal or leg arteries is unknown, the paucity of published cases suggesting the event is either uncommon or unrecognized.Gross examples of a phenomenon are important because they are easily recognized and may be the extreme variants of events which are commonly unspectacular or undetectable.It is with this possibility in mind that a case in which mural thrombus in the thoracic aorta formed emboli to the abdominal and leg arteries is reported. CASE REPORTAn unmarried woman (U.O.H. 363216) aged 67 had for many years noticed slight breathlessness and constricting pain in the centre of the chest when walking.She was admitted to a cottage hospital complaining of pain in the right loin, vomiting, and weakness for nine days.Her temperature was 99.60 F. (37.60 C.) and blood- pressure 190/90 mm.Hg.No abnormalities were found in the abdomen or chest.The urine contained moderate quantities of protein, but the centrifuged deposit showed neither red nor white cells.The blood urea was 53 mg./100 ml.Her pain continued for five days and several examinations failed to establish its cause.She was transferred to the Radcliffe Infirmary, where examination showed a sinus rhythm of 96/minute.The only pulses in the legs were the femorals; her blood-pressure was 125/80 mm.Hg.Crepitations were present in both lungs, but there were no cardiac murmurs and no abdominal abnormalities.The urine had a specific gravity of 1018, it contained between 300 and 1,000 mg. of protein per litre, and the centrifuged deposit had 8 white cells and several hyaline and granular casts per high-power field.The blood urea was 48 mg./100 ml.; plasma sodium 130, potassium 4.2, chloride 90, and bicarbonate 20 mEq/l.The plasma amylase was 7 units.The haemoglobin was 99%; white cells 20,000/cu.mm.-a neutrophil leucocytosis; the sedimentation rate was 97 mm./hour.The next day her loin pain increased and she complained of pain in the legs.Examination revealed tenderness in the right hypo- chrondrium.The following day her legs were cold and white, and bowel sounds were absent.On the third day she sweated profusely, the pulse was 120/minute and the systolic blood-pressure 50 mm.Hg, despite metaraminol and hydrocortisone.Faeculent material was aspirated from the stomach.She died on the seventeenth day