Parikh A, Vacek T P
Wright State University, Cardiology, Dayton, OH, USA.
Oxf Med Case Reports. 2018 Mar 14;2018(3):omx105. doi: 10.1093/omcr/omx105. eCollection 2018 Mar.
Occurrence of paradoxical arterial embolism may cause the first symptoms in patients with a coexisting hypercoagulable state and patent foramen ovale (PFO). This can result in significant morbidity and mortality depending on the location of the embolism. The risks and benefits of closure of small PFOs have not been well elucidated in prior studies. We describe a patient with a history of Factor V Leiden heterozygosity who presented with left arm pain secondary to arterial embolism. The patient was a 51-year-old male who initially presented to the emergency department after awaking from sleep with progressive, severe, burning left arm pain. He had also noted intermittent shortness of breath over the 2 weeks prior to admission. Temperature was 97.4 F, pulse 86, respiratory rate 20 and blood pressure 121/87. Oxygen saturation was 94% on supplemental oxygen. He had a cool left upper extremity and the patient described subjective paresthesias in this extremity. Left radial pulse was difficult to palpate. Physical exam was otherwise unremarkable. Troponin I was mildly elevated at 0.217 ng/l. White blood cell count was 11.8 and INR 1.1. EKG showed sinus tachycardia with non-specific T abnormalities in the anterior leads. His past medical history was notable for only hypertension and hyperlipidemia. Current recommendation is for antiplatelet or anticoagulation for those with hypercoaguable states who suffer a stroke; there is currently no absolute indication for closure device. We describe the case of a 51-year-old male who had presented with left arm pain and shortness of breath. The computed tomography (CT) angiography of chest showed pulmonary emboli with heavy clot burden bilaterally. Heparin was started, but patient was found to have occlusion along large arteries of the left arm. Emergent left axillary, brachial, radial and ulnar embolectomy for acute critical arm ischemia were performed. The transthoracic echocardiogram done the next day with bubble study was positive for patent foramen ovale. Hypercoaguability showed factor V Leiden heterozygosity. Decision was made for the patient to initiate long-term anticoagulation with rivaroxaban and closure was performed. Patient was advised that closure is off label but opted to proceed with closure in light of hypercoaguable state.
矛盾性动脉栓塞的发生可能是患有并存的高凝状态和卵圆孔未闭（PFO）患者的首发症状。这可能会根据栓塞的部位导致显著的发病率和死亡率。既往研究尚未充分阐明小型PFO封堵的风险和益处。我们描述了一名患有因子V莱顿杂合子病史的患者，该患者因动脉栓塞出现左臂疼痛。患者为一名51岁男性，最初在从睡眠中醒来后因进行性、严重、烧灼样左臂疼痛而就诊于急诊科。他还注意到入院前2周内有间歇性呼吸急促。体温为97.4°F，脉搏86次/分，呼吸频率20次/分，血压121/87。吸氧时氧饱和度为94%。他的左上肢发凉，患者描述该肢体有主观感觉异常。左侧桡动脉搏动难以触及。体格检查其他方面无异常。肌钙蛋白I轻度升高至0.217 ng/l。白细胞计数为11.8，国际标准化比值（INR）为1.1。心电图显示窦性心动过速，前壁导联有非特异性T波异常。他既往的病史仅以高血压和高脂血症为显著特征。目前的建议是，对于患有高凝状态且发生中风的患者进行抗血小板或抗凝治疗；目前尚无封堵装置的绝对适应证。我们描述了一名51岁男性出现左臂疼痛和呼吸急促的病例。胸部计算机断层扫描（CT）血管造影显示双侧有大量血栓负荷的肺栓塞。开始使用肝素，但发现患者左臂大动脉有闭塞。因急性严重手臂缺血紧急进行了左腋窝、肱动脉、桡动脉和尺动脉取栓术。第二天进行的经胸超声心动图及气泡试验显示卵圆孔未闭呈阳性。高凝状态显示因子V莱顿杂合子。决定让患者开始使用利伐沙班进行长期抗凝，并进行封堵。告知患者封堵属于未获批准的应用，但鉴于其高凝状态，患者选择进行封堵。
