An unusual case of SADDLE Pulmonary Thrombo Embolism

Pulmonary thromboembolism is a serious health problem with significant morbidity and mortality. It is the result of migration of clots from systemic veins to the pulmonary circulation. The true incidence of venous thromboembolism is difficult to estimate because of the often silent nature of the condition. In the Western World, the incidence is one case of Deep Vein Thrombosis (DVT) and 0.5 case of Pulmonary Embolism per 1000 population/ year. Most pulmonary emboli arise from deep veins in the legs. Pulmonary emboli can also arise from pelvic veins in Women. Venous thromboembolism along with stroke and myocardial infarction rank as three big cardiovascular killers in India. They are increasingly being diagnosed and treated in tertiary care hospitals in India and world over due to increased awareness and availability of advanced diagnostic modalities. Saddle thromboembolus is a large thromboembolus lodged at the bifurcation of pulmonary trunk. It is an uncommon manifestation of massive Pulmonary Thrombo Embolism (PTE) as it has been reported to be detected in 1% of cases after death and in 1.6% of cases through Contrast Enhanced Computed Tomography (CECT) scans. Hence antemortem diagnosis of saddle pulmonary thromboembolism is very difficult, as these patient either die or too ill for any diagnostic imaging. Saddle PTE previously was mostly diagnosed at necropsy. Therefore it was regarded as one of the most severe forms of Pulmonary Embolism. CECT plays an important role in the identification of saddle thromboembolus as a filling defect within the column of contrast material at the bifurcation of pulmonary artery. Here in this case report we present a saddle PTE in a 50 year old smoker presented with DVT of his right lower limb venous system and all investigations for hypercoagulable states were negative. This patient had a large saddle thromboembolus with pulmonary infarction and he was successfully managed with anticoagulants without the need for surgical intervention.