DVT, PULMONARY EMBOLISM, AND PARADOXICAL EMBOLISM THANKS TO A CARDIAC CONNECTION

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Concomitant venous and arterial thrombi are usually seen in hypercoagulable states, but we present an unusual case where a patient developed paradoxical embolism of deep venous thrombosis (DVT) and pulmonary embolism (PE) leading to acute limb ischemia due to the presence of a patent foramen ovale (PFO). CASE PRESENTATION: 70-year-old female with history of OSA, hypertension, diabetes on insulin presented to the hospital with sudden onset right lower extremity pain, numbness and weakness of few hours. Patient also complained of dyspnea on exertion that started about 3 weeks prior. At presentation, patient was hypoxic, and examination demonstrated a right lower extremity that was cold to touch and numb with faint dorsalis pedis and posterior tibialis pulses on the right compared to the left. CT chest, abdomen, pelvis with contrast showed an acute extensive pulmonary emboli with right heart strain, acute thrombus at the origin of the celiac trunk, superior and inferior mesenteric arteries, left lower pole renal artery, right common femoral artery, and left internal iliac artery with occlusion of the right common femoral, left internal iliac, and left lower pole renal arteries. Lower extremity venous doppler showed an acute deep venous thrombosis of the left popliteal vein and the femoral vein in the lower thigh. 2D echo with bubble study revealed D-shaped left ventricle due to septal flattening, consistent with elevated right ventricular pressure atrial septal aneurysm and a patent foramen ovale. Patient was started on heparin drip and emergently taken to the operating room for right lower extremity thrombo-embolectomy of right iliac, right femoral, right profunda, right superficial femoral artery, right popliteal artery and 4 compartment fasciotomies. Post-operatively, anticoagulation was changed to Rivaroxaban and was discharged to acute inpatient rehab in stable condition. DISCUSSION: The prevalence of PFO in the general population is more than 25% but most are asymptomatic, the prevalence of DVT was found to be as high as 41% in one study of patients with suspected paradoxical embolism and concomitant patent foramen ovale. Most of the data about PFO closure are for prevention of recurrent cryptogenic stroke with paucity of data on how to manage PFO and paradoxical embolism causing limb ischemia with associated DVT and PE. CONCLUSIONS: A high index of suspicion for PFO should be maintained when a patient with PE and/or DVT presents with concomitant evidence of arterial thromboembolism. Reference #1: 1.Stollberger C, Slany J, Schuster I, Leitner H, Winkler W, Karnik R. The Prevalence of Deep Venous Thrombosis in Patients with Suspected Paradoxical Embolism. Ann Intern Med. 1993;119:461–465. doi: 10.7326/0003-4819-119-6-199309150-00003 Reference #2: 2.Homma, S. and R. L. Sacco (2005). "Patent foramen ovale and stroke.” Circulation 112(7): 1063-1072. DISCLOSURES: No relevant relationships by Nellowe Candelario, source=Web Response No relevant relationships by Adegbola Oluwole, source=Web Response