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Catastrophic Paradoxical Embolism FREE TO VIEW

Nathan Wilds*, MD; Eric Yim, MD; Arthur Headley, MD
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University of Tennessee Health Science Center, Memphis, TN

Chest. 2012;142(4_MeetingAbstracts):355A. doi:10.1378/chest.1390547
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SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Paradoxical embolism is a rare, yet well characterized complication of venous emboli. We present a patient who was found to have a saddle pulmonary embolism. Further investigation revealed evidence of arterial emboli as well. CT angiography confirmed the diagnosis of paradoxical embolism, through a patent foramen ovale(PFO).

CASE PRESENTATION: A 47-year-old female with a past medical history of hypertension and diabetes presented with acute onset of shortness of breath, pain, and weakness of her left arm. The patient had sustained 3rd degree burns to her left lower extremity approximately three weeks prior. A CT scan of the chest was done, revealing a large intra-cardiac thrombus with multiple, bilateral, upper and lower lobe emboli. Upon exam, the patient had decreased capillary refill of left hand, as well as an absent radial pulse. An ultrasound of left upper extremity vasculature revealed patent vessels with abnormal low-resistance waveforms. Further review of the previous CT chest was suspicious for filling defects in the left subclavian artery, aortic arch, and descending aorta. CT angiography of the aortic arch and great vessels showed extensive clot extending from the ascending to descending aorta. The left subclavian artery was almost completely occluded as well. Echocardiography revealed increased right ventricular pressure, and a PFO. An IVC filter was prophylactically placed as lower extremity ultrasound revealed further clots in femoral and deep femoral veins. The patient was emergently taken to the operating room, where embolectomy of both pulmonary arteries and aorta was performed with primary PFO closure. The patient developed lower limb ischemia requiring bilateral arterial embolectomies, as well as bilateral four compartment fasciotomies. Postoperatively the patient developed left lateral gaze and right hemiplegia, clinically indicative of left middle cerebral arterial stroke.

DISCUSSION: Paradoxical embolism has been documented to be a cause of catastrophic systemic emboli(1). Treatment guidelines have only trended toward improvement yet rely heavily on patient's individual risk factors and extend of clot burden(2).

CONCLUSIONS: We present an unfortunate case of catastrophic venous and paradoxical arterial embolism through a PFO. Surgical, as well as medical treatment with fibrinolytics, have been suggested, both yielding very high mortality rates. Here, both anticoagulation and surgery were attempted unsuccessfully in a patient with catastrophic paradoxical emboli.

1) Meachem R, Headley A, et al. Impending Paradoxical Embolism. Arch Internal Med.1998;158:438-448.

2) Myers B, Bounameaux H, et all. Impending Paradoxical Embolism. Chest. 2010;137:164-170.

DISCLOSURE: The following authors have nothing to disclose: Nathan Wilds, Eric Yim, Arthur Headley

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University of Tennessee Health Science Center, Memphis, TN




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