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Blackburn AF, Landinez GP, Kerlan RK, Lokken RP. Malposition of a Femoral Tunneled Dialysis Catheter through a Patent Foramen Ovale. Semin Intervent Radiol 2023; 40:304-307. [PMID: 37484443 PMCID: PMC10359127 DOI: 10.1055/s-0043-1769745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Patent foramen ovale (PFO) is a common congenital abnormality of high prevalence in adults. Its clinical significance is magnified in a right-to-left shunt, where paradoxical embolism can have catastrophic outcomes involving the brain, heart, mesenteric circulation, or extremities. Right-to-left shunting through a PFO is caused by increased right atrial pressure, as seen in the setting of pulmonary artery hypertension or pulmonary embolism. This case highlights the relevance of central venous catheter placement in the setting of a PFO. While the patient did not experience clinical sequelae from line placement, she was at high risk for paradoxical embolus. Recognizing the possibility of a PFO during central venous catheter placement, especially in the setting of increased right pressures, should be a consideration of all interventional radiologists.
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Affiliation(s)
- Anthony Finnay Blackburn
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Gina P. Landinez
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Robert K. Kerlan
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - R. Peter Lokken
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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Houtzager T, Berg I, Urlings T, Grauss R. Concomitant pulmonary embolism and upper limb ischaemia as a first presentation of a patent foramen ovale. BMJ Case Rep 2021; 14:e242351. [PMID: 34598956 PMCID: PMC8488715 DOI: 10.1136/bcr-2021-242351] [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] [Accepted: 09/14/2021] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Tessa Houtzager
- Emergency Medicine, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
| | - Ingvar Berg
- Emergency Medicine, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
| | - Thijs Urlings
- Radiology, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
| | - Robert Grauss
- Cardiology, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
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Jolobe O. Wide-ranging clinical spectrum of paradoxical embolism. Postgrad Med J 2021; 98:958-966. [PMID: 34006630 DOI: 10.1136/postgradmedj-2020-139691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/23/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
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.
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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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Miriyala V, Awan MU, Faraj K, Nagra B. Traversing boundaries: thrombus in transit with paradoxical embolism. J Community Hosp Intern Med Perspect 2016; 6:31438. [PMID: 27609716 PMCID: PMC5016836 DOI: 10.3402/jchimp.v6.31438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 11/27/2022] Open
Abstract
A 72-year-old male is diagnosed with paradoxical embolus after he presented with concurrent deep vein thrombosis, stroke, and multiple arterial emboli in the presence of a patent foramen ovale (PFO). Paradoxical embolus requires the passage of a thrombus from the venous into the arterial circulation through a right-to-left shunt leading to systemic embolism. But, despite the high incidence of PFO (27.3% across all age groups by autopsy), paradoxical embolism (PDE) is uncommon, representing <2% of all arterial emboli. We present a case report where a thrombus has been directly observed passing through the PFO during an echocardiogram study; thus, clearly delineating the true cause of multiple thromboemboli and stoke in our patient. Subsequent Transesophageal Echocardiography (TEE) also interestingly showed the thrombus in transit in the aorta and pulmonary artery.
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Affiliation(s)
- Varun Miriyala
- Seton Hall University School of Health and Medical Sciences (St Francis) Program, Trenton, NJ, USA;
| | - Muhammad Umer Awan
- Seton Hall University School of Health and Medical Sciences (St Francis) Program, Trenton, NJ, USA
| | - Kirmanj Faraj
- Capital Health Regional Medical Center, Trenton, NJ, USA
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Chen L, Deng W, Palacios I, Inglessis-Azuaje I, McMullin D, Zhou D, Lo EH, Buonanno F, Ning M. Patent foramen ovale (PFO), stroke and pregnancy. J Investig Med 2016; 64:992-1000. [PMID: 26988903 PMCID: PMC6083869 DOI: 10.1136/jim-2016-000103] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO)-related stroke is increasingly recognized as an important etiology of ischemic embolic stroke-accounting for up to 50% of strokes previously considered 'cryptogenic' or with an unknown mechanism. As a 'back door to the brain,' PFO can allow venous clots to enter arterial circulation via interatrial right-to-left shunting, potentially resulting in ischemic stroke. We observe that clinically, PFO-related stroke affects women of childbearing age, and that pregnancy-owing to major changes in hemocoagulative, hormonal, and cardiovascular parameters-can enhance stroke risks. However, no systematic study has been performed and little is known regarding complications, pregnancy outcomes and treatment for PFO-related stroke during pregnancy. To identify and characterize the complications and clinical outcomes related to PFOs during pregnancy, we performed a literature review and analysis from all reported cases of pregnancy with PFO-related complications in the medical literature from 1970 to 2015. We find that during pregnancy and post-partum, PFO is associated with complications affecting multiple organs, including the brain, heart and lung. The three principal complications reported are stroke, pulmonary emboli and myocardial infarction. In contrast to other pregnancy-related stroke etiologies, which peak during later pregnancy and postpartum, PFO-related stroke peaks during early pregnancy (first and second trimester-60%), and most patients had good neurological outcome (77%). In patients with PFO with recurrent stroke during pregnancy, additional key factors include high-risk PFO morphology (atrial septal aneurysm), larger right-to-left shunt, multiple gestation and concurrent hypercoagulability. Compared to strokes of other etiologies during pregnancy, most PFO stroke patients experienced uneventful delivery (93%) of healthy babies with a good clinical outcome. We conclude with recommended clinical treatment strategies for pregnant patients with PFO suggested by the data from these cases, and the clinical experience of our Cardio-Neurology Clinic.
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Affiliation(s)
- Lei Chen
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, West China Hospital in Sichuan University, Chengdu, China
| | - Wenjun Deng
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Igor Palacios
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ignacio Inglessis-Azuaje
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David McMullin
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dong Zhou
- Department of Neurology, West China Hospital in Sichuan University, Chengdu, China
| | - Eng H Lo
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ferdinando Buonanno
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - MingMing Ning
- Department of Neurology, Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Chisci E, Ercolini L, Romano E, Troisi N, Michelagnoli S. Successful hybrid management of extensive thromboembolism of the innominate trunk, right subclavian artery, bilateral common carotid artery, and pulmonary embolism. Ann Vasc Surg 2014; 28:1566.e1-5. [PMID: 24524957 DOI: 10.1016/j.avsg.2013.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/14/2013] [Accepted: 12/29/2013] [Indexed: 11/28/2022]
Abstract
Symptomatic acute carotid occlusion demands treatment, but the exact treatment to be provided in the case of acute occlusion of 3 supra-aortic vessels is not well established. Herein, we describe the successful emergency hybrid management of a massive thromboembolic occlusion of the right subclavian artery, common carotid artery, and innominate trunk, associated with left arm hemiparesis, motor aphasia, and confusion, and extensive pulmonary embolism. The diagnostic work-up and the hybrid surgical strategy adopted are described. Neurologic symptoms had completely regressed at discharge and the patient was free of any complications at the 3-month follow-up.
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Affiliation(s)
- Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy.
| | - Leonardo Ercolini
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Eugenio Romano
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Nicola Troisi
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
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CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients. AJR Am J Roentgenol 2013; 201:753-63. [PMID: 24059364 DOI: 10.2214/ajr.13.11208] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE CT angiography using modern MDCT scanners has evolved into a highly accurate noninvasive diagnostic tool for the evaluation of patients with pathologic abnormalities of the upper extremity arterial system. CONCLUSION Here we focus on the use of this modality in patients with nontraumatic vascular pathologic abnormalities.
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Bibliography—Editors’ selection of current world literature. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31829d7cd1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park MS, Park JP, Yun SH, Lee JU, Kim JK, Lee NE, Song JE, Lee SE, John SH, Lim JH, Rhew JY. A case of cryptogenic stroke associated with patent foramen ovale coexisting with pulmonary embolisms, deep vein thromboses, and renal artery infarctions. Korean Circ J 2013; 42:853-6. [PMID: 23323125 PMCID: PMC3539053 DOI: 10.4070/kcj.2012.42.12.853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 05/10/2012] [Accepted: 05/12/2012] [Indexed: 11/11/2022] Open
Abstract
A paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt, and is commonly related to patent foramen ovale (PFO). However, coexisting pulmonary embolisms, deep vein thromboses (DVT), and multipe systemic arterial embolisms, associated with PFO, are rare. Here, we report a patient who had a cryptogenic ischemic stroke, associated with PFO, which is complicated with a massive pulmonary thromboembolism, DVT, and renal infarctions, and subsequently, the patient was treated using a thrombolytic therapy.
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Affiliation(s)
- Moon-Sik Park
- Division of Cardiology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
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Rajani AR, Hussain K, Baslaib FO, Radaideh GA. A unique presentation of four thrombotic events at a time. BMJ Case Rep 2012. [PMID: 23188853 DOI: 10.1136/bcr-2012-007221] [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
A 72-year-old man was referred to our hospital as a case of postcardiac arrest following a long distance air flight. Work-up in the emergency department revealed the presence of deep vein thrombosis (DVT), bilateral pulmonary embolism, inferior STEMI (ST elevation myocardial infarction) and ischaemic stroke. He received thrombolysis by recombinant tissue plasminogen activator (tPA) following which his haemodynamic status improved, but he developed haemorrhagic transformation of the stroke as a complication. The haemorrhagic lesion gradually resolved with conservative management, leaving behind a residual neurological deficit. His haemodynamic status was stable after the management. Although a diagnosis of right-to-left shunt lesion was highly suggestive in this condition, it could not be confirmed on the transthoracic echocardiogram. Our patient had a unique presentation of multiple thrombi in different organs that caused significant morbidity and haemodynamic instability. There are no well-established guidelines that discuss the acute management of such cases. This situation requires a careful assessment and management of the patient by a multidisciplinary team.
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Affiliation(s)
- Ali Raza Rajani
- Department of Cardiology, Rashid Hospital, Dubai Health Authority, United Arab Emirates.
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