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Deep venous thrombosis and pulmonary emboli: case report A 42-year-old woman developed deep venous thrombosis (DVT) and bilateral segmental and subsegmental pulmonary emboli during treatment with ethinylestradiol/levonorgestrel for contraception [duration of treatment to reactions onsets not stated]. The woman, who never smoked or consumed alcohol, presented with symptoms consistent with acute right upper limb ischaemia. She reported a 2-week history of exertional right upper limb pain along with associated coolness. She was a highintensity endurance athlete. She had completed a 42km marathon a week prior to onset of these symptoms. CT angiography showed a long brachial artery occlusion in the cubital fossa. Her outpatient venous duplex ultrasound study was suggestive of right lower limb DVT within the soleal and tibial veins. It was noted that she was on oral ethinylestradiol/levonorgestrel 30/150µg pill for contraception. Her thrombophilia and vasculitic screens were negative. Thus, CT pulmonary angiography was performed, which revealed subsegmental and bilateral segmental pulmonary emboli. She developed paradoxical embolism possibly due to the pulmonary emboli. The onset of DVT and pulmonary emboli was attributed to ethinylestradiol/levonorgestrel. Subsequently, her transthoracic echocardiography showed a right-to-left atrial-level shunt consistent with patent foramen ovale (PFO). Thereafter, the woman underwent a brachial arteriotomy with a transverse arteriotomy and embolectomy. An angiography revealed ulnar spasm with residual thrombus in the radial artery, requiring another embolectomy. She was treated with nitroglycerin [glyceryl trinitrate] to reduce spasm. She had an unremarkable recovery and was discharged on postoperative day 2. She was prescribed heparin in the postoperative period for anticoagulation before switching to oral apixaban anticoagulant, which was continued until her PFO was closed. Her ethinylestradiol/levonorgestrel pill was changed to a progestin intrauterine device. Gondoputro W, et al. An unusual case of upper limb ischemia in a marathon runner. Journal of Vascular Surgery Cases and Innovative Techniques 6: 160-164, No. 1, Mar 803500089 2020. Available from: URL: http://doi.org/10.1016/j.jvscit.2020.01.017

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