Lower limb vein thrombosis-induced pulmonary embolism and paradoxical multiple arterial embolisms: A case report with a 10-year follow-up

Abstract

Introduction: Paradoxical embolism (PDE) refers to direct passage of venous thrombi into the arterial circulation through an arteriovenous shunt. It is well-known that the pulmonary thromboembolism (PTE) can cause opening of the foramen ovale leading to paradoxical arterial embolism. Long term follow up of PDE patient over 10 years was not reported in the literature.

Patient concerns: A 57-year-old woman presented with initial symptoms of numbness/weakness and hypoxemia. Ultrasonography and pulmonary arteriography indicated pulmonary thromboembolism.

Diagnosis: Pulmonary embolism and paradoxical multiple arterial embolism or acute PTE concomitant with paradoxical multiple arterial embolism.

Interventions: Craniectomy and anticoagulation treatment was administered and the patient received low-dose warfarin therapy for 10 years.

Outcomes: The patient is currently stable with no abnormalities seen in the deep veins of the bilateral lower limbs. The international normalized ratio (INR) was controlled within the range of 1.20 to 1.51. As this is a 10-year follow-up case report, the patient has responded well to the treatment and has been followed-up. The follow-up has been annual and the patient has been stable CONCLUSION:: Low intensity and persistent anticoagulation therapy can inhibit blood thrombophilia and reduce the risk of bleeding. It is noteworthy that such an approach used effectively in this patient. To best our knowledge, it is first report for long term follow up PDE patient successfully over 10 years.

Figure 1

Imaging examinations. Cranial computed tomography (CT) indicated changes after the right temporal decompressive craniectomy (A). Vascular ultrasound revealed solid low echoes at the distal end of the right subclavian artery (B). computed tomography pulmonary arteriography (CTPA) showed wide embolism at the distal end of the bilateral main pulmonary arteries (C). A vascular ultrasound of the neck revealed solid low echoes at the right internal carotid artery (D). The mesenteric arteriovenous ultrasound showed that, the sonolucency of the main trunk and partial branches was poor with no blood flow filling (as indicated by the arrows) (E). Echocardiography indicated the color trans-septal blood flow signals were explored at the oval foramen (as indicated by the arrows) (F).

Figure 2

A schematic diagram of a foramen ovale opening and closing. In a normal heart, the foramen ovale closes, separating the right atrium (RA) and the left atrium (LA) (A). p ulmonary thromboembolism (PTE) induces an increase in pulmonary arterial pressure and also right cardiac pressure, leading to an enlargement of the right side of the heart and the opening of the foramen ovale, venous blood leaks from the right atrium through the left atrium into the body (B). After anticoagulant therapy, the patient's pulmonary arterial pressure returned to normal, transesophageal ultrasonic examination found that the foramen ovale had been closed (C).