Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report

BACKGROUND To date,this is the first case of a paradoxical embolism(PDE)that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter(CVC)thrombus via a patent foramen ovale(PFO).CASE SUMMARY Here,we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC.The patient presented to the hospital with acute chest pain and lower limb fatigue.Doppler ultrasound showed a large thrombus in the right internal jugular vein,precisely at the tip of the CVC.Transthoracic and transesophageal echocardiography confirmed the existence of a PFO,with inducible right-to-left shunting by the Valsalva maneuver.The patient was administered an extended course of anticoagulation therapy,and then the CVC was successfully removed.Percutaneous PFO closure was not undertaken.There was no recurrence during follow-up.CONCLUSION Thus,CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.

Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

Patent foramen ovale (PFO) is a common congenital cardiac defect. It is usually asymptomatic, but it can be associated with relevant clinical manifestations such as cryptogenic stroke and platypnea-orthodeoxia syndrome. We present the case of a patient with hemodynamically significant carotid artery stenosis who underwent endarterectomy for a transient ischemic attack (TIA). After surgery, the patient presented an ischemic stroke due to M2 occlusion treated with mechanical thrombectomy. During hospitalization, a distal bilateral deep vein thrombosis was found. The patient developed respiratory failure due to a massive right-to-left shunt through a large PFO (platypnea-orthodeoxia syndrome). These findings are consistent with the hypothesis that the TIA and the subsequential ischemic stroke were related to paradoxical embolism rather than atherothromboembolism. The aim of our case report is to raise awareness of the possible complications of such a common finding as PFO.

Acute inferior ST-segment elevation myocardial infarction cryptogenic stroke caused by a paradoxical embolism with pulmonary embolism and previous a concomitant

A 61-year-old woman was hospitalized for a chief complaint of sudden chest tightness with sweating for two hours. The chest tightness and sweating occurred suddenly and without remission after a morning stool. Electrocardiography showed a complete atrioventricular （AV） block and arc-like elevation of the ST-segment in leads Ⅱ, Ⅲ, AVF, V7-V9, and V3R-V5R, at about 0.05-0. 15 mV. After being administered 1 mg of atropine in the emergency room （ER）, the patient was admitted to the cardiology department. The patient had been found in a cyanotic state two years previously, but did not receive any treatment; she was diagnosed with a transient ischemic attack （TIA） 1.5 years previously because of limb dyskinesia accompanied by slurred speech.

Pulmonary embolism and impending paradoxical embolism： a case report

A definitive diagnosis of paradoxical embolism is ,based on the evidence that a thrombus crosses through the right-to-left shunting. We report a case of impending paradoxical embolism in a patient with pulmonary embolism diagnosed by echocardiography and proved by operation later.

Paradoxical embolism:Experiences from a single center

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 recom-mend long-term anticoagulation therapy to prevent the recurrence of PDE, especially to those with an intracardiac communication or persistent risk factors for re-thrombosis.

Large eustachian valve fostering paradoxical thromboembolism:passive bystander or serial partner in crime?

Catheter-based closure of patent foramen ovale(PFO)is more effective than medical therapy in the prevention of recurrent stroke[1].It is likely that a proportion of patients evaluated for potential transcatheter PFO closure has actually different anatomical variants particularly common in the right atrium such as eustachian valve,Chiari network,Thebesian valve and Crista Terminalis.Notably,the eustachian valve may represent an increased risk factor for left circulation thromboembolism beyond that associated with PFO size and shunting.Such patients may benefit the most from percutaneous closure procedure.

Suspected cerebrovascular air embolism during endoscopic esophageal varices ligation under sedation with fatal outcome: A case report

BACKGROUND Air embolism is a very rare,yet serious and potentially fatal complication of digestive endoscopic treatment.Air embolism is the result of air directly entering the arteries or veins.However,to recognize neurological dysfunction under sedation can be difficult.Therefore,it is extremely important to identify high-risk groups and take preventive measures.CASE SUMMARY Herein,we report a 74-year-old female patient with esophageal varices who suffered from consciousness disturbance after the third endoscopic ligation of esophageal varices under sedation.Combined with the patient’s imaging examination results and medical history,we highly suspected that the patient had developed paradoxical cerebral air embolism during endoscopic ligation.We learned that the patient died at a later follow-up.In order to be able to identify and prevent the occurrence of air embolism early,we summarize and analyze the risk factors,pathogenesis,clinical manifestations,prevention and treatment options of gastrointestinal endoscopy complicated by cerebral air embolism.CONCLUSION Electroencephalographic monitoring helps to recognize the occurrence of air embolism in time and increase the patient's chance of survival.

Successful outcome of massive carbon dioxide embolism during laparoscopic hepatectomy

Carbon dioxide embolism is a rare but severe complication of laparoscopic hepatectomy.We reported a case of massive carbon dioxide embolism that developed into a rare paradoxical gas embolism during laparoscopic hepatectomy and resulted in reduced muscular power of the left upper extremity,severe pleural effusion and hypoalbuminemia after surgery.Fortunately,the patient fully recovered with positive prevention and postoperative treatment.This case report highlights that the surgeon and anaesthesiologist must be aware of the risks and the importance for prompt treatment when massive carbon dioxide embolism occurs.

Transient ischemic attack induced by pulmonary arteriovenous fistula in a child:A case report

BACKGROUND Cerebral ischemic stroke is attributed to paradoxical cerebral embolism.Pulmonary arteriovenous fistula(PAVF)is a rare potential cause of cerebral ischemic stroke,and cerebral ischemic stroke induced by PAVF in children is rare.CASE SUMMARY We report a case of right PAVF that presented as a transient ischemic attack(TIA)in a 13-year-old boy.The patient underwent embolization therapy and remained clinically stable for 2 years after treatment.CONCLUSION TIA induced by PAVF in children is rare,lacks typical clinical manifestations,and should not be ignored.

Intraoperative management of liver transplant in a patient with an undiagnosed ventricular septal defect:A case report

BACKGROUND The intraoperative management of patients undergoing orthotopic liver transplantation(OLT)frequently encounters hemodynamic instability after reperfusion of the new liver graft.The resulting post-reperfusion syndrome is characterized by an increase in pulmonary vascular resistance and decrease in systemic vascular resistance.In the presence of a left to right intracardiac shunt,this hemodynamic perturbance can lead to shunt reversal followed by hypoxemia and embolization of air and debris into the systemic circulatory system.CASE SUMMARY A 43 years-old male with end-stage liver disease due to primary sclerosing cholangitis complicated by portal hypertension and hepatocellular carcinoma presented for an OLT.A bedside transthoracic echocardiography(TTE)was performed immediately before the procedure and unexpectedly identified a ventricular septal defect(VSD).The patient and the surgical team agreed to proceed with the surgery as it was a time critical donation after circulatory organ death.We developed an intraoperative plan to optimize pulmonary and systemic pressures using vasoactive support,optimized mechanical ventilation,and used transesophageal echocardiography(TEE)for intraoperative monitoring.During reperfusion,considerable turbulent flows with air were noted in the right ventricle,but no air was visualized in the left ventricle.Color flow Doppler showed no reversal flow in the VSD.At the end of the procedure,the patient was extubated in the operating room without complication and was transferred to the transplant unit for recovery.CONCLUSION Our case highlights the importance of echocardiography in the perioperative assessment of patients undergoing liver transplantation.The TTE findings obtained immediately before the procedure and the real-time use of intraoperative TEE to modify our management during the critical phases of the transplant resulted in continuity of care and a good surgical outcome for this patient.