Najib Khalid, Heckle Mark, Goubran Sameh, Mehta Rhadika, Goswami Rohan, Khouzam Rami N
University of Tennessee Health Science Center, Methodist University Hospital, Memphis, TN, USA.
Ann Transl Med. 2018 Jan;6(1):21. doi: 10.21037/atm.2018.01.04.
A paradoxical embolism is defined as a systemic arterial embolus due to passage of a venous thrombus through a right to left shunt. We describe a case of acute cerebral vascular accident (CVA), right subclavian arterial embolus, and pulmonary emboli in the setting of a large patent foramen ovale (PFO). A 74-year-old woman with multiple comorbidities presented to the emergency department with acute onset of shortness of breath, weakness, and right arm pain. She was found to have bilateral pulmonary emboli, left CVA, and a right subclavian arterial embolus on computed tomography (CT). She emergently underwent embolectomy of her right upper extremity along with a fasciotomy. On chest CT, a PFO was visualized. Transesophageal echocardiogram (TEE) revealed a large PFO with at least a 3-mm primum/secundum separation and evidence of right to left shunting. Multidisciplinary consensus was that she would benefit from closure of her PFO in order to reduce her risk of further emboli. The patient was agreeable and taken to the catheterization lab where a sizing balloon over a stiff wire was advanced to measure the size of the defect. A 25-mm Cardioform device was successfully delivered across the defect. The patient was started on oral anticoagulation and antiplatelets. In summary, increase in right-sided pressures from pulmonary emboli can cause right to left shunting and lead to a paradoxical embolus. Assessment of patients who present with acute CVA or arterial embolus in the setting of pulmonary emboli with elevated right atrial pressures should include an evaluation for a PFO. Closure of PFO in these patients is of potential additive benefit.
反常栓塞定义为静脉血栓通过右向左分流进入体循环动脉而形成的动脉栓塞。我们描述了一例在大的卵圆孔未闭（PFO）情况下发生急性脑血管意外（CVA）、右锁骨下动脉栓塞和肺栓塞的病例。一名患有多种合并症的74岁女性因急性起病的气短、乏力和右臂疼痛就诊于急诊科。计算机断层扫描（CT）显示她有双侧肺栓塞、左侧CVA和右锁骨下动脉栓塞。她紧急接受了右上肢栓子切除术及筋膜切开术。胸部CT显示有一个PFO。经食管超声心动图（TEE）显示一个大的PFO，原发孔/继发孔至少分离3mm，并有右向左分流的证据。多学科共识认为，她将从PFO封堵术中获益，以降低进一步发生栓塞的风险。患者表示同意，被送往导管室，在一根硬导丝上推进一个测量球囊以测量缺损大小。一个25mm的Cardioform装置成功通过缺损处植入。患者开始口服抗凝药和抗血小板药物。总之，肺栓塞导致的右心压力升高可引起右向左分流并导致反常栓塞。对于在肺栓塞且右心房压力升高的情况下出现急性CVA或动脉栓塞的患者，评估应包括对PFO的评估。对这些患者进行PFO封堵可能会带来额外的益处。
