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Paradoxical arterial embolism (PDE) may cause the first symptoms in patients with a coexisting hypercoagulable state and PFO. Most pts with PFO are asymptomatic. However, in the younger population it could be the underlying etiology of recurrent arterial embolus events, such as cryptogenic stroke or peripheral embolism. We are presenting a case with PDE secondary to DVT and PE in the presence of PFO
65 yo F presented to the ED c/o severe right arm pain and SOB. Vitals were normal. Exam was unremarkable. However, right upper limb pulses were not palpable. Labs and CXR were unremarkable. Pt was taken urgently to the cath lab. A peripheral angiogram showed acute right axillary artery thrombosis, which was treated with stent and thrombectomy. CTA of the chest showed a large saddle PE. TEE revealed moderate dilitation of RV and elevated RVSP. Bubble study showed intra-atrial shunt. US revealed LLE DVT. Hypercoagulable study revealed MTHF mutation with hyper-homocysteinemia
We believe it was highly possible that the acute limb ischemia was due to a paradoxical clot through the PFO in the setting of elevated RVSP due to PE. Of all the cases of systemic arterial emboli, the paradoxical arterial emboli have the lowest incidence, but are frequently associated with cryptogenic stroke as well as peripheral embolism. Some pts with PDE have a PFO, ASD, or an atrial septal aneurysm. However, identification of one or more of these atrial septal abnormalities in a pt with an ischemic event does not prove to have a causal relationship since other sources or conduits of embolism may also be present. The likelihood of paradoxical embolism secondary to PFO increases with the presence of these important elements: a venous source of thrombus, PE, and intracardiac shunt. Probable mechanisms for this may be due to transient increase in RAP, use of the Valsalva maneuver, or increase in RVSP due to PE. The patient had the four main elements for diagnosis paradoxical arterial embolism. She had DVT, PE, and elevated RVSP with PFO. All of these incidents increase the likelihood that her acute arterial thrombus was secondary to PDE
Paradoxical embolization is an uncommon but devastating complication of PE.
Poster Hall, Hall F
Saturday, March 16, 2019, 3:45 p.m.-4:30 p.m.
Session Title: FIT Clinical Decision Making: Interventional Cardiology 2
Abstract Category: Interventional Cardiology
Presentation Number: 1166-196
- 2019 American College of Cardiology Foundation