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A 39 year old previously healthy man presented with a painful, cold, and pulseless right leg. His past medical history was uneventful. In particular, the patient had never experienced chest pain. Upon questioning, he remembered that three months earlier he had suffered intermittent right shoulder pain with irradiation to the right arm lasting a few days. Subsequently, he noticed a decreased exercise capacity. Routine ECG showed Q waves and ST segment elevation in the precordial leads suggestive of prior anterior myocardial infarction with left ventricular aneurysm. Echocardiography (left) confirmed the diagnosis, demonstrating an apical aneurysm and a large apical mural thrombus (arrow) (RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle). Lower extremity digital subtraction angiography (right) showed multiple thromboembolic occlusions of the right femoral bifurcation, the right superficial femoral artery, and the right popliteal artery with the classical “meniscus” sign (arrow). The absence of peripheral vascular disease, the involvement of the femoral bifurcation, the multiple localisation of the occlusions, and the clear cut-off of the contrast dye are typical angiographic signs of embolic occlusions.
Surgical embolectomy was performed. Elective coronary angiography showed a tight stenosis at the bifurcation of the left anterior descending coronary artery with the first diagonal branch. This lesion was successfully treated by percutaneous transluminal coronary angioplasty. Postprocedural treatment included aspirin and coumadin. At the three month follow up there was no evidence of further embolic events.
Our case illustrates that, even in young patients, owing to its atypical or silent presentation, a large myocardial infarction may go unrecognised and manifest itself only by the occurrence of an infarct related complication.