Paradoxical embolism-report of a case involving four organ systems

Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report

BACKGROUND

To date, this is the first case of a paradoxical embolism (PDE) that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter (CVC) thrombus via a patent foramen ovale (PFO).

CASE SUMMARY

Here, we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC. The patient presented to the hospital with acute chest pain and lower limb fatigue. Doppler ultrasound showed a large thrombus in the right internal jugular vein, precisely at the tip of the CVC. Transthoracic and transesophageal echocardiography confirmed the existence of a PFO, with inducible right-to-left shunting by the Valsalva maneuver. The patient was administered an extended course of anticoagulation therapy, and then the CVC was successfully removed. Percutaneous PFO closure was not undertaken. There was no recurrence during follow-up.

CONCLUSION

Thus, CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.

Concomitant pulmonary embolism and upper limb ischaemia as a first presentation of a patent foramen ovale

A 78-year-old female patient presented to the emergency department with syncope and dyspnoea. The left arm appeared to be cold and radial pulse was not palpable. A CT scan of the chest and left arm with intravenous contrast displayed bilateral central pulmonary embolisms in combination with a left subclavian artery embolism and an atrial septal aneurysm. Transthoracic echocardiography identified a patent foramen ovale with right-to-left shunting confirming the diagnosis of paradoxical embolism. The patient was treated with anticoagulants. In a patient presenting with a combination of a pulmonary embolism and a peripheral arterial embolism, the clinician should consider a right-to-left shunt with paradoxical embolism. In line with this, when diagnosing a peripheral arterial embolism, a central venous origin should be considered. Furthermore, when diagnosing a pulmonary embolism or other forms of venous thromboembolism, the clinician should be aware of signs of a peripheral arterial embolism.

Wide-ranging clinical spectrum of paradoxical embolism

The purpose of this review is to raise the index of suspicion for paradoxical embolism among generalists. The review is based solely on anecdotal reports compiled from EMBASE, MEDLINE, Googlescholar and Pubmed. Search terms were 'paradoxical embolism', 'pulmonary embolism' and 'pulmonary arteriovenous malformations'. What emerged was that right-to-left paradoxical embolism could occur with or without concurrent pulmonary embolism, and also with and without proof of the presence of an 'embolus-in-transit'. Potential sites of single or multiple systemic involvement included the central nervous system, the coronary circulation, renal arterial circulation, splenic circulation, the mesenteric circulation and the limbs. In many cases, the deep veins of the lower limbs were the source of thromboembolism. In other cases, thrombi originated from an atrial septal aneurysm, from a central venous line, from a haemodialysis-related arterio-venous shunt, from a popliteal vein aneurysm, internal jugular vein, superior vena cava, from a pulmonary arteriovenous malformation, from tricuspid valve endocarditis (with and without pulmonary embolism) and from the right atrium, respectively. Stroke was by far the commonest systemic manifestation of paradoxical embolism. Some strokes were attributable to pulmonary arteriovenous malformations with or without coexistence of intracardiac shunts. Clinicians should have a high index of suspicion for paradoxical embolism because of its time-sensitive dimension when it occurs in the context of involvement of the intracranial circulation, coronary circulation, mesenteric circulation, and peripheral limb circulation.

Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke

High-risk PE can be complicated by the presence of a patent foramen ovale (PFO), which can lead to paradoxical systemic embolization, including cerebral embolism ultimately leading to acute ischemic stroke (AIS). Acute management is challenging given the competing benefits and risks of systemic thrombolysis. Herein, we aim to provide a review of clinical presentations, diagnostic findings, and treatment and outcome from the available literature, with the hopes of providing insight into treatment options. We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic literature search using PubMed/MEDLINE database, Cochrane Library, and Google Scholar for all reported cases/case series of concomitant high-risk PE and paradoxical ischemic stroke was conducted from inception to July 2019. Twenty-nine cases from 27 articles (26 single case reports, 1 case series of 3 patients) were included. There were 10 men and 19 women, ranging in age from 29 to 81 years (mean 56.1 ± 13.5 years). PFO was diagnosed in 89.7% of patients, mostly by transesophageal echocardiography. Treatment modalities included systemic thrombolysis (40%), anticoagulation alone (36%), surgical thrombectomy (16%), and percutaneous thrombectomy (8%). Overall mortality rate was 31%. Patients receiving thrombolysis and surgical thrombectomy had the most favorable outcome. Survival to discharge was 90% (9 out of 10), 100% (5 out of 5), and 50% (4 out of 8) in the systemic thrombolysis, surgical thrombectomy, and anticoagulation alone groups respectively. In the setting of combined high-risk PE and ischemic stroke, PFO can be detected in 90% of published cases. Thrombolysis and surgical thrombectomy seem to be effective management, but further studies are needed for validation.

Simultaneous Multifocal Paradoxical Embolism in an Elderly Patient with Patent Foramen Ovale: A Case Report

About one-third of ischemic strokes may be associated with a patent foramen ovale (PFO). This article presents an unusual case of a 68-year-old woman with simultaneous paradoxical thrombo-embolization to different systemic sites. The patient presented initially with visual deficits and intracerebellar hemorrhage but was found to have concomitant saddle pulmonary embolism, sub-acute cerebral infarction with focal neurological deficits, and thromboembolism to the superior mesenteric artery (SMA) that resulted in an ischemic bowel. The unifying diagnosis was paradoxical embolism through a PFO and an atrial septal aneurysm with high-risk features. The patient underwent percutaneous closure of the PFO with an Amplatzer device.

Paradoxical Brain Embolism Caused by Pulmonary Arteriovenous Fistula and Coincident Pulmonary Embolism

The authors encountered a very rare case of paradoxical brain embolism resulting from pulmonary arteriovenous fistula and coincident pulmonary embolism. Enhanced computed tomography was useful for diagnosing this infrequent condition.

A case of a patient with protein C deficiency presenting with concurrent thromboses in the pulmonary arteries and innominate artery: a suggestive computed tomographic finding of thrombophilia

The incidence of arterial thrombosis in patients with protein C deficiency is relatively low compared with that of venous thrombosis. To our knowledge, there is no previously published report of a protein C deficiency patient with simultaneous thromboses in the pulmonary artery and innominate artery in the English literature. We present a case of a protein C deficiency in which the presence of concurrent clots in the pulmonary arteries and innominate artery demonstrated on a pulmonary computed tomographic angiography provided an important clue permitting diagnosis of the deficiency.

Fatal pulmonary embolism and coincidental cerebral infarction after spinal anesthesia -A case report-

A pulmonary embolism and cerebral infarction are the second and third most common acute cardiovascular diseases after a myocardial infarction. Early diagnosis and appropriate management are important clinical challenges. In this case, a fatal pulmonary embolism and extensive cerebral infarction caused cardiac arrest during spinal anesthesia for total hip replacement surgery. Transesophageal echocardiography indicated a pulmonary embolism and brain CT showed large area of acute infarction at right middle cerebral artery territory. Pulmonary CT angiogram revealed massive pulmonary embolism findings. This paper reviews this case and suggests other preventive modalities.

Ongoing paradoxical particulate embolism during megaprosthesis placement

Pulmonary embolism (PE) by solid particles is an infrequent complication encountered during orthopedic procedures. A patent foramen ovale (PFO) allows embolic material into the left-sided circulation, potentially affecting several organs. A case of a 33-year-old woman undergoing total proximal femur resection with megaprosthesis reconstruction is presented. Towards the end of surgery, cement was injected to stabilize the prosthesis. Echodense particulate matter was first seen in the right atrium, subsequently in the right ventricle, and also in significant quantities in the left atrium and ventricle. This was accompanied by significant changes in partial pressure of arterial oxygen. Despite the aforementioned disturbances, hemodynamic stability was observed throughout the event. Postoperative follow-up showed persistent hypoxemia but no other abnormalities. This intriguing case of embolism via particulate material in a patient with PFO during hip replacement surgery allows review of the physiology and pathophysiology of PE phenomena.

Paradoxical embolization via a patent foramen ovale following acute pulmonary embolism

The foramen ovale is usually obliterated following establishment of the adult circulation but remains patent in 25% of individuals. This potential communication between the venous and arterial circulations can allow thromboembolic material to bypass the lungs and enter the systemic circulation. We report two cases of paradoxical embolization through a patent foramen ovale following acute large pulmonary embolism (PE) and discuss the factors that predispose to paradoxical embolization following PE.

Concurrent cerebral and axillary artery occlusion: a possible source of cerebral embolization from peripheral artery thrombosis

Intracranial embolization usually arises from heart, precerebral artery or aorta but rarely the peripheral artery as retrograde upstream of embolus should be overcome. We encountered a woman who experienced a transient right acronumbness followed by a sudden onset of left hemiplegia and conscious change concurrently. Cranial computerized tomography revealed a hemorrhagic infarct at right lentiform nucleus. Angiography disclosed right axillary artery occlusion at the proximal portion without collateral circulation. Cardioaortic survey and coagulation profile were normal. Thrombectomy was done and radial flow was corrected rapidly. Post-thrombectomic heparinization did not bring complication. Therefore, a distant embolism from peripheral artery at the upper limb should be alerted for cerebral ischemia. A lower density of embolus and no-flow condition in her occluded axillary artery may facilitate the upstreamed embolization. Heparinization, under closed monitor, is not contraindicated for preventing restenosis after thrombectomy in case of hemorrhagic transformation in brain.

CASE REPORTS: Intracardiac Thrombosis in Multiple Chambers and Descending Aorta Manifested as Systemic and Pulmonary Thromboembolism

We report a case with multiple thrombosis that underwent sudden circulatory collapse due to acute pulmonary embolism and ischemic stroke. Further confirmed by transesophageal echocardiography, the thrombus in both atria was detected by transthoracic echocardiography. In addition, patent foramen ovale and another thrombus in the descending aorta were readily identified by transesophageal echocardiography. Aspirin was prescribed and thrombi disappeared 1 month later. Our case report suggests that patients undergoing sudden collapse with unexplained hypoxemia and new neurological deficit secondary to coexistence of pulmonary and systemic embolism should be promptly evaluated by echocardiography, especially transesophageal one, with high suspicion for paradoxical embolism.

Paradoxical coronary embolism causing non-ST segment elevation myocardial infarction in a case of pulmonary embolism

We describe the case of a 61-year-old woman who simultaneously suffered a pulmonary embolism and a myocardial infarction due to paradoxical coronary artery embolism. Transesophageal echocardiography with injection of agitated hydroxyethyl starch revealed a patent foramen ovale. Thrombophlebistis of the left saphenous vein with extension of thrombus into the femoral vein could be identified as the source of embolism. Paradoxical coronary embolism is an underrecognized cause of MI. Diagnosis is particularly difficult, when MI and PE coincide, because of the similarity in clinical signs and symptoms of both entities. A high level of clinical suspicion and echocardiography, especially if performed soon after presentation, can be the clue to early diagnosis of PDE.

[Cardiogenic shock due to acute mitral dysfunction after deep venous thrombosis]

Open surgical embolectomy may be life-saving in massive pulmonary embolism. Up to now there are no studies concerning the question whether the foramen ovale should be examined routinely during surgery and whether an open foramen ovale should be closed routinely in the same session. Even case reports regarding this question are missing. We report on a 74-year old female patient who developed pulmonary embolism due to deep venous thrombosis. Six days after successful surgical embolectomy the patient developed cardiogenic shock due to a huge thrombus from the right atrium through the foramen ovale into the left atrium and the left ventricle. Immediate surgical embolectomy of a 40-50 cm huge thrombus was successful. Immediately after surgery upon the cardiac mass the patient showed symptoms of acute right leg ischemia. Thus a second embolectomy was necessary, the surgeon removed a 10 cm thrombus from the right external iliacal artery. There was no evidence of another pulmonary embolism timely related to the paradoxical embolism.

Paradoxical embolism to the left main coronary artery: visualization by transesophageal echocardiography

A case of myocardial infarction is described with transesophageal echocardiography visualization of left main coronary artery thrombus arising from paradoxical embolism of mobile venous thrombus by patent foramen ovale.