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Lu J, Morton C, Hall M, Nagarsheth K. Paradoxical Embolism Is an Unusual Etiology of Acute Limb Ischemia in Patients Suffering from COVID-19 Infection. Vasc Endovascular Surg 2024; 58:13-19. [PMID: 37338815 DOI: 10.1177/15385744231185641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Acute limb ischemia (ALI) is a large contributor to morbidity and mortality annually and can be managed either operatively or medically. ALI is most often caused by arterial embolism or in situ thrombosis and treatment is often dependent upon the severity. Anticoagulation is considered standard of care and first line therapy. However, more severe cases of ALI require surgical intervention.Paradoxical emboli are a rare and potentially under-appreciated cause of ALI. They arise when venous emboli, from a variety of sources, traverse a patent foramen ovale (PFO) to enter the arterial system, compromising blood flow to the affected end organ. In most cases, they can only be proven if the thrombus is identified as it crosses the cardiac defect, at which point it is an indication for surgery requiring PFO closure, management for the ischemia itself, and possible intervention for the embolism.In this report, we identify and discuss management of a series of cases where ALI was precipitated by PFOs that were discovered in the context of a pulmonary emboli that developed into paradoxical emboli. All patients had a confirmed diagnosis of COVID-19 which has been associated with a state of hypercoagulability and subsequent thrombus formation.
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Affiliation(s)
- Jeffrey Lu
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Claire Morton
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Michael Hall
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Khanjan Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
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Percutaneous closure of patent foramen ovale for paradoxical embolism in acute limb ischemia. Cardiovasc Interv Ther 2018; 34:282-284. [PMID: 30109674 PMCID: PMC6561983 DOI: 10.1007/s12928-018-0542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/09/2018] [Indexed: 10/31/2022]
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Kleber FX, Hauschild T, Schulz A, Winkelmann A, Bruch L. Epidemiology of Myocardial Infarction Caused by Presumed Paradoxical Embolism via a Patent Foramen Ovale. Circ J 2017; 81:1484-1489. [DOI: 10.1253/circj.cj-16-0995] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Franz X. Kleber
- Cardio Centrum Berlin Academic Teaching Institution, Charité University Medicine Berlin
| | - Telse Hauschild
- Ernst von Bergmann Klinikum Potsdam, Academic Teaching Hospital, Charité University Medicine Berlin
| | - Antonia Schulz
- Cardio Centrum Berlin Academic Teaching Institution, Charité University Medicine Berlin
| | - Anne Winkelmann
- Unfallkrankenhaus Berlin, Academic Teaching Hospital, Charité University Medicine Berlin
| | - Leonhard Bruch
- Unfallkrankenhaus Berlin, Academic Teaching Hospital, Charité University Medicine Berlin
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Cachia M, Pace Bardon M, Fsadni P, Montefort S. Systemic and venous thromboembolism: think about paradoxical embolism. BMJ Case Rep 2015. [PMID: 26220984 DOI: 10.1136/bcr-2015-211174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patent foramen ovale (PFO) is one of the most important causes of paradoxical embolism; it is found in about 25-30% of the population. In most patients, it is asymptomatic and diagnosis is usually made during routine echocardiography. In a small proportion of patients, PFO is diagnosed after paradoxical embolism is suspected. We present a case of a middle-aged smoker who was admitted with lower limb deep vein thrombosis and pulmonary embolism, who developed acute upper limb ischaemia during his inpatient stay. Since doctors might dismiss such cases as routine, this report highlights the importance of detailed history taking and examination in patients with venous thromboembolism. Paradoxical embolism should always be considered as a possible diagnosis when managing patients with concomitant venous and arterial embolism.
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Affiliation(s)
- Monique Cachia
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | | | - Peter Fsadni
- Department of Medicine, Mater Dei Hospital, Msida, Malta
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Wąsek WC, Samul W, Ryczek R, Skrobowski A. Unique case of ST-segment-elevation myocardial infarction related to paradoxical embolization and simultaneous pulmonary embolization: clinical considerations on indications for patent foramen ovale closure in no-guidelines land. Circulation 2015; 131:1214-23. [PMID: 25825398 DOI: 10.1161/circulationaha.114.009846] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Robert Ryczek
- From the Military Institute of Medicine, Warsaw, Poland
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Rovera C, Biasco L, Orzan F, Belli R, Omedè P, Gaita F. Percutaneous implantation of a second device in patients with residual right-to-left shunt after patent foramen ovale closure. J Interv Cardiol 2014; 27:548-54. [PMID: 25421752 DOI: 10.1111/joic.12162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The management of patients with residual right-to-left shunt (rRLS) after percutaneous patent foramen ovale (PFO) closure is debated. The aim of this study was to define the incidence of moderate-to-large rRLS and to report the feasibility, safety and long-term clinical outcome of transcatheter closure of rRLS. METHODS AND RESULTS From June 2000 to March 2013, 322 subjects underwent percutaneous PFO closure. In 39 patients (12.1%) with moderate-to-large rRLS on transcranial Doppler (TCD) and/or transesophageal echocardiogram a second cardiac catheterization was performed with the aim of completing the closure. A second closure device was implanted in 21 patients (53.8%). In the remaining 18 (46.2%), a second device was not delivered for the following reasons: in 13 (72.2%) no residual passage could be crossed, in 5 (27.8%) the residual shunt was deemed to be negligible. No complications occurred. After the second procedure, complete closure was proved by TCD in 16/21 (76.2%) subjects. One patient received a third device. During follow-up (41 ± 19 months), no cerebrovascular ischemic accidents occurred. CONCLUSION A second percutaneous PFO occlusion device can be safely implanted in patients with significant rRLS. However, a moderate-to-large rRLS on TCD and/or TEE may not necessarily represent a significant risk of further paradoxical embolization.
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Affiliation(s)
- Chiara Rovera
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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Pirkl M, Myjavec A, Daněk T, Černý M. A case of pulmonary thromboembolism with synchronous and metachronous paradoxical embolism through the patent foramen ovale - a case report. COR ET VASA 2012. [DOI: 10.1016/j.crvasa.2012.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Patent Foramen Ovale (PFO) is a normal fetal communication between right and left atria that persists after birth by about 30% in adults. It is discussed to be associated to potential clinical events, asking rational of such closure. Its correction throughout venous access can be attempted on four different indications: (1) secondary prevention of stroke or transient ischemic attack, (2) decompression illness, (3) migraine with aura, and (4) platypnea-orthodeoxia. The PFO closure procedure implies the double control of X-rays and ultrasound, and is relatively simple to perform, using various prostheses. In France, the place of percutaneous closure procedure is nowadays unclear since the Haute Autorité de santé currently suspended recommendations about the management after stroke.
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Schmitt R, Westhoff-Bleck M, Haller H, Wagner AD. Paradoxical renal embolism in a patient with congenital cardiac malformation. QJM 2011; 104:885-7. [PMID: 21047811 DOI: 10.1093/qjmed/hcq200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R Schmitt
- Department of Nephrology and Hypertension, Medical School Hannover, 30625 Hannover, Germany.
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Dao CN, Tobis JM. PFO and paradoxical embolism producing events other than stroke. Catheter Cardiovasc Interv 2011; 77:903-9. [DOI: 10.1002/ccd.22884] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/15/2010] [Accepted: 10/19/2010] [Indexed: 11/07/2022]
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Ronco F, Rigatelli G, Dell'Avvocata F, Giordan M, Ronco C, Cardaioli P. Embolic renal infarct, patent foramen ovale and coronary artery dissection: a strange case of cardio-renal connection. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:67.e5-7. [DOI: 10.1016/j.carrev.2010.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 02/14/2010] [Accepted: 03/01/2010] [Indexed: 11/25/2022]
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Association of a Patent Foramen Ovale With Myocardial Infarction and Pulmonary Emboli in a Peripartum Woman. Am J Med Sci 2010; 340:326-8. [DOI: 10.1097/maj.0b013e3181e732b2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Patent foramen ovale is found in 24% of healthy adults and 38% of patients with cryptogenic stroke. This ratio and case reports indicate that patent foramen ovale and stroke are associated, probably because of paradoxical embolism. In healthy people with patent foramen ovale, embolic events are not more frequent than in controls, and therefore no primary prevention is needed. However, once ischaemic events occur, the risk of recurrence is substantial and prevention becomes an issue. Acetylsalicylic acid and warfarin reduce this risk to the same level as in patients without patent foramen ovale. Patent foramen ovale with a coinciding atrial septal aneurysm, spontaneous or large right-to-left shunt, or multiple ischaemic events potentiates the risk of recurrence. Transcatheter device closure has therefore become an intriguing addition to medical treatment, but its therapeutic value still needs to be confirmed by randomised-controlled trials.
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Affiliation(s)
| | - B. Meier
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - K. Nedeltchev
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
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Majunke N, Wallenborn J, Baranowski A, Wunderlich N, Sievert H. Device closure of residual shunt after percutaneous closure of patent foramen ovale. EUROINTERVENTION 2010; 5:833-7. [DOI: 10.4244/eijv5i7a139] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mangiafico S, Scandura S, Ussia GP, Privitera A, Capodanno D, Petralia A, Tamburino C. Transesophageal echocardiography and transcranial color Doppler: independent or complementary diagnostic tests for cardiologists in the detection of patent foramen ovale? J Cardiovasc Med (Hagerstown) 2009; 10:143-8. [DOI: 10.2459/jcm.0b013e32831fb210] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Extracerebral paradoxical embolisms in patients with intracardiac shunts. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:190-1. [PMID: 18606385 DOI: 10.1016/j.carrev.2008.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Accepted: 01/08/2008] [Indexed: 11/21/2022]
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