Greenberg Jason W, Goff Zackary D, Mooser Annie C, Wittgen Catherine M, Smeds Matthew R
Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO.
Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO.
Ann Vasc Surg. 2020 Jul;66:668.e5-668.e10. doi: 10.1016/j.avsg.2019.12.022. Epub 2020 Jan 2.
Paradoxical embolism is the translocation of a thrombus originating in the systemic venous circulation into the arterial circulation through a cardiac defect, most commonly a patent foramen ovale (PFO). PFO exists in 15-35% of the adult population. The most common manifestation is cerebrovascular accident; acute limb ischemia is much rarer.
A 67-year-old woman with multiple confounding risk factors for hypercoagulability presented with grade IIb left lower limb ischemia secondary to thromboembolism through a previously silent PFO. Management included urgent embolectomy, prophylactic fasciotomy, postoperative anticoagulation, and PFO closure. A systematic literature review of PFO-mediated acute limb ischemia was performed to identify the patient populations most commonly affected, the anatomic distribution of emboli, and patient management.
Forty-three reports including 51 patients with first-time PFO-mediated paradoxical embolism were identified. Fifty-one percent were men, and the average age at presentation was 54 years. Multiple limbs were affected in 14 patients (27.5%), and a propensity for the lower limbs (72%) and left-sided circulation (82%) was noted. Deep venous thromboembolism was identified in 36 patients (71%). Immediate anticoagulation was instituted in 31 patients. Embolectomy and/or fibrinolysis were performed in 45 patients (88%).
Acute limb ischemia is a rare manifestation of PFO-mediated paradoxical embolism that requires a high index of suspicion for diagnosis. Middle-aged individuals appear to be more commonly affected, and acute limb ischemia most often occurs in the lower limbs and left-sided circulation, with the potential to affect multiple extremities simultaneously. Prompt identification and surgical embolectomy with prophylactic fasciotomy can facilitate successful outcomes. Perioperative management should include anticoagulation and may include workup with echocardiography, duplex ultrasound, and hypercoagulability testing.
反常栓塞是指起源于体循环静脉系统的血栓通过心脏缺损进入动脉循环，最常见的是卵圆孔未闭（PFO）。15% - 35%的成年人群存在卵圆孔未闭。最常见的表现是脑血管意外；急性肢体缺血则较为罕见。
一名67岁女性，有多种导致高凝状态的混杂危险因素，因通过此前未被发现的卵圆孔未闭发生血栓栓塞继发IIb级左下肢缺血前来就诊。治疗措施包括紧急取栓术、预防性筋膜切开术、术后抗凝以及卵圆孔未闭封堵术。对卵圆孔未闭介导的急性肢体缺血进行了系统的文献综述，以确定最常受影响的患者群体、栓子的解剖分布以及患者的治疗方法。
共识别出43篇报告，包括51例首次因卵圆孔未闭介导的反常栓塞患者。其中51%为男性，就诊时的平均年龄为54岁。14例患者（27.5%）多个肢体受累，发现下肢（72%）和左侧循环（82%）更易受累。36例患者（71%）发现存在深静脉血栓栓塞。31例患者立即进行了抗凝治疗。45例患者（88%）进行了取栓术和/或纤维蛋白溶解治疗。
急性肢体缺血是卵圆孔未闭介导的反常栓塞的罕见表现，诊断时需要高度怀疑。中年个体似乎更常受累，急性肢体缺血最常发生在下肢和左侧循环，有可能同时影响多个肢体。及时识别并进行手术取栓及预防性筋膜切开术有助于取得成功的治疗结果。围手术期管理应包括抗凝治疗，可能还包括超声心动图、双功超声检查以及高凝状态检测。
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