Nondiagnostic intraoperative transesophageal echocardiography preceding CT-confirmed pulmonary embolism: A case report
- 1Corresponding author at: Department of Anesthesiology and Pain Management, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
- 2Department of Anesthesiology and Pain Management, The MetroHealth System, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
Abstract
Intraoperative pulmonary embolism (PE) is a rare but potentially fatal perioperative complication, particularly in lower extremity orthopedic surgery. Transesophageal echocardiography (TEE) is a principal intraoperative bedside imaging tool for evaluating suspected PE; however, its sensitivity depends on thrombus location and patient factors. We present a 32-year-old man with morbid obesity who developed hypoxia refractory to 100% fraction of inspired oxygen (FiO₂), recruitment maneuvers and increased positive end-expiratory pressure (PEEP), with presumed hypotension, during open reduction and internal fixation of a left ankle fracture. Intraoperative TEE was nondiagnostic and reported normal biventricular size and function, whereas an earlier transthoracic study had shown right ventricular dilation. Postoperative CT angiography showed an acute PE in the right main pulmonary artery extending into bilateral segmental and subsegmental arteries, with right heart strain. The patient underwent successful mechanical thrombectomy and was discharged on anticoagulation. This case highlights the limits of TEE for detecting intraoperative PE, the hazard of false reassurance from a technically limited study, and the value of indirect signs such as a widened arterial–end-tidal carbon dioxide (PaCO₂–EtCO₂) gradient and right ventricular dilation.
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BibTeX
@article{riyanair2026nondiagnostic,
title = {{Nondiagnostic intraoperative transesophageal echocardiography preceding CT-confirmed pulmonary embolism: A case report}},
author = {Riya Nair, BS and Faria Nisar, MD and Ryan Kaplevatsky, DO and Christopher Boutton, CRNA and Bushra Abdul-Aleem, MD},
journal = {JCA Advances},
year = {2026},
month = oct,
doi = {10.1016/j.jcadva.2026.100289},
url = {https://doi.org/10.1016/j.jcadva.2026.100289},
note = {CC BY},
}
RIS
TY - JOUR
TI - Nondiagnostic intraoperative transesophageal echocardiography preceding CT-confirmed pulmonary embolism: A case report
AU - Riya Nair, BS
AU - Faria Nisar, MD
AU - Ryan Kaplevatsky, DO
AU - Christopher Boutton, CRNA
AU - Bushra Abdul-Aleem, MD
PY - 2026
DA - 2026/10/30
JO - JCA Advances
DO - 10.1016/j.jcadva.2026.100289
UR - https://doi.org/10.1016/j.jcadva.2026.100289
AB - Intraoperative pulmonary embolism (PE) is a rare but potentially fatal perioperative complication, particularly in lower extremity orthopedic surgery. Transesophageal echocardiography (TEE) is a principal intraoperative bedside imaging tool for evaluating suspected PE; however, its sensitivity depends on thrombus location and patient factors. We present a 32-year-old man with morbid obesity who developed hypoxia refractory to 100% fraction of inspired oxygen (FiO₂), recruitment maneuvers and increased positive end-expiratory pressure (PEEP), with presumed hypotension, during open reduction and internal fixation of a left ankle fracture. Intraoperative TEE was nondiagnostic and reported normal biventricular size and function, whereas an earlier transthoracic study had shown right ventricular dilation. Postoperative CT angiography showed an acute PE in the right main pulmonary artery extending into bilateral segmental and subsegmental arteries, with right heart strain. The patient underwent successful mechanical thrombectomy and was discharged on anticoagulation. This case highlights the limits of TEE for detecting intraoperative PE, the hazard of false reassurance from a technically limited study, and the value of indirect signs such as a widened arterial–end-tidal carbon dioxide (PaCO₂–EtCO₂) gradient and right ventricular dilation.
SN - 2950-5534
ER -