Paradoxical embolism: Experiences from a single center

Abstract

Objective: To present our treatment experiences and the follow-up data of patients with paradoxical embolism (PDE).

Methods: The clinical characteristics, management, and follow-up data of all included patients who were diagnosed with PDE at Fuwai Hospital from January 1994 to October 2015 were recorded.

Results: Twelve patients were included; all had a pulmonary embolism, and 8 had deep venous thrombosis. The artery embolisms involved the cerebral artery (7 patients), renal artery (2 patients), mesentery artery (2 patients), popliteal artery (1 patient), descending aorta thrombus (1 patient), and thrombus-straddled patent foramen ovale (PFO) (1 patient). PFO was found in 3 cases. One patient underwent thrombectomy and PFO closure; Six patients received thrombolysis; and 3 patients were implanted with a vena cava filter. Long-term anticoagulation with warfarin was recommended for each patient. One patient died from ventricular fibrillation despite cardiopulmonary resuscitation. Eleven patients were discharged with improvements. No late mortality occurred in 8 patients with a complete follow-up of 10.6-17.7 years. One had a recurrent deep venous thrombosis. No patient had a recurrent pulmonary or arterial embolism. Two patients changed their treatment from warfarin to aspirin; others remained on warfarin. Only 1 case had an occasional gum bleeding.

Conclusions: PDE treatment including thrombolysis, anticoagulation, and embolectomy should be individualized. We recommend long-term anticoagulation therapy to prevent the recurrence of PDE, especially to those with an intracardiac communication or persistent risk factors for re-thrombosis.

Keywords: Deep venous thrombosis; Paradoxical embolism; Patent foramen ovale; Pulmonary embolism.

Fig. 1

Computed tomography of the chest in case 9 before thrombolysis. The major pulmonary artery is enlarged. The distal right pulmonary artery is partly occluded; the left upper lobular artery is nearly totally occluded; and there is a thrombus floating in the lumen of the descending aorta. The arrows point to the thrombus.

Fig. 2

Computed tomography of the chest in case 9 after thrombolysis before discharge. The major pulmonary artery is enlarged. The walls of the right pulmonary artery and left upper lobular artery are irregular and thick. The thrombus in the distal right pulmonary artery is partly resolved, and the left upper lobular artery is partly recanalized. The thrombus floating in the lumen of the descending aorta disappeared. The arrows point to the thrombus.