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Li JD, Xu N, Zhao Q, Li B, Li L. Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report. World J Clin Cases 2024; 12:842-846. [PMID: 38322689 PMCID: PMC10841136 DOI: 10.12998/wjcc.v12.i4.842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
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.
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Affiliation(s)
- Jian-Duan Li
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Nian Xu
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Qiang Zhao
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Biao Li
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Li Li
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
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Blackburn AF, Landinez GP, Kerlan RK, Lokken RP. Malposition of a Femoral Tunneled Dialysis Catheter through a Patent Foramen Ovale. Semin Intervent Radiol 2023; 40:304-307. [PMID: 37484443 PMCID: PMC10359127 DOI: 10.1055/s-0043-1769745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Patent foramen ovale (PFO) is a common congenital abnormality of high prevalence in adults. Its clinical significance is magnified in a right-to-left shunt, where paradoxical embolism can have catastrophic outcomes involving the brain, heart, mesenteric circulation, or extremities. Right-to-left shunting through a PFO is caused by increased right atrial pressure, as seen in the setting of pulmonary artery hypertension or pulmonary embolism. This case highlights the relevance of central venous catheter placement in the setting of a PFO. While the patient did not experience clinical sequelae from line placement, she was at high risk for paradoxical embolus. Recognizing the possibility of a PFO during central venous catheter placement, especially in the setting of increased right pressures, should be a consideration of all interventional radiologists.
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Affiliation(s)
- Anthony Finnay Blackburn
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Gina P. Landinez
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Robert K. Kerlan
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - R. Peter Lokken
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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Nwosu I, Ibeson E, Singh S, Singh R, Gulati A, Zadushlivy D, Kupfer Y, Derman A, Clemen B, Basnet A, Nsofor G, Ogar AU. Paradoxical Thromboembolic Ischemic Stroke Following Tissue Plasminogen Activator Instillation for Clogged Central Venous Dialysis Catheter. Cureus 2021; 13:e20346. [PMID: 35036188 PMCID: PMC8752339 DOI: 10.7759/cureus.20346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2021] [Indexed: 11/20/2022] Open
Abstract
Central venous catheters including dialysis catheters are a potential source of venous thrombosis and pose a risk for paradoxical embolic events including ischemic stroke and systemic embolism in patients with a patent foramen ovale (PFO). The adult population with a PFO and patients with a central venous dialysis catheter (CVDC) are at increased risk of a paradoxical embolic event. Since bubble study is not routinely done during echocardiogram in a patient with CVDC, it is difficult to identify at-risk patients for paradoxical embolic events during catheter manipulation, especially for clogged CVDC. We report a rare case of a 79-year-old lady with end-stage renal disease on hemodialysis (HD) using a CVDC who developed a paradoxical embolic ischemic stroke following the use of tissue plasminogen activator (tPA) for unclogging a dialysis catheter. We aimed to highlight the existing risks of thromboembolism associated with the long-term use of central CVDC, especially the potential risk of paradoxical embolism and ischemic stroke with the use of tPA for management of clogged dialysis catheters. We emphasize the questionable need for a bubble study echocardiogram in all patients requiring long-term dialysis catheters.
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Jolobe O. Wide-ranging clinical spectrum of paradoxical embolism. Postgrad Med J 2021; 98:958-966. [PMID: 34006630 DOI: 10.1136/postgradmedj-2020-139691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/23/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
The purpose of this review is to raise the index of suspicion for paradoxical embolism among generalists. The review is based solely on anecdotal reports compiled from EMBASE, MEDLINE, Googlescholar and Pubmed. Search terms were 'paradoxical embolism', 'pulmonary embolism' and 'pulmonary arteriovenous malformations'. What emerged was that right-to-left paradoxical embolism could occur with or without concurrent pulmonary embolism, and also with and without proof of the presence of an 'embolus-in-transit'. Potential sites of single or multiple systemic involvement included the central nervous system, the coronary circulation, renal arterial circulation, splenic circulation, the mesenteric circulation and the limbs. In many cases, the deep veins of the lower limbs were the source of thromboembolism. In other cases, thrombi originated from an atrial septal aneurysm, from a central venous line, from a haemodialysis-related arterio-venous shunt, from a popliteal vein aneurysm, internal jugular vein, superior vena cava, from a pulmonary arteriovenous malformation, from tricuspid valve endocarditis (with and without pulmonary embolism) and from the right atrium, respectively. Stroke was by far the commonest systemic manifestation of paradoxical embolism. Some strokes were attributable to pulmonary arteriovenous malformations with or without coexistence of intracardiac shunts. Clinicians should have a high index of suspicion for paradoxical embolism because of its time-sensitive dimension when it occurs in the context of involvement of the intracranial circulation, coronary circulation, mesenteric circulation, and peripheral limb circulation.
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Di Stefano V, Di Fulvio M, Di Liberato L, Onofrj M, De Angelis MV. Paradoxical embolism through a patent foramen ovale from central venous catheter thrombosis: A potential cause of stroke. J Neurol Sci 2020; 414:116820. [PMID: 32276106 DOI: 10.1016/j.jns.2020.116820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 03/27/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
Paradoxical embolism refers to a potential condition in which an embolus arising from a venous source crosses into the systemic circulation through a right-to-left cardiac shunt causing an arterial embolism. A 39-year-old woman carrier of a central venous catheter (CVC) without evident risk factors for stroke, developed an acute right homonymous hemianopia during hemodialysis. On neuroimaging, an infarct in the territory of the left posterior cerebral artery was demonstrated. Transesophageal echocardiography revealed a patent foramen ovale (PFO) and a large fluctuating thrombus in the right atrium on the tip of the CVC, thus allowing a diagnosis of ischemic stroke from paradoxical embolism. Oral anticoagulation therapy was started and the PFO was closed. This case emphasizes the potential risk of paradoxical embolism in patients with CVCs and PFO. This condition should be prevented and identified in patients with specific risk factors, such as long-term catheterization and hemodialysis.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy.
| | - Maria Di Fulvio
- Department of Cardiology and Cardiac Surgery, "G. d'Annunzio" University, Chieti, Italy
| | - Lorenzo Di Liberato
- Department of Medicine, Institute of Nephrology, "SS. Annunziata" Hospital, Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
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Abstract
Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.
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A case of paradoxical cerebral infarction by spraying thrombus in the catheter for dialysis. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0124-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Kiyohara T, Mizoguchi T, Kuroda J, Wakisaka Y, Irie A, Kitaoka C, Fujisaki K, Nakamura U, Tsuruya K, Kitazono T, Ago T. Repeated Paradoxical Brain Infarctions in a Patient on Self-Managed Home Hemodialysis Using a Long-Term Indwelling Catheter. J Stroke Cerebrovasc Dis 2017; 26:e183-e185. [PMID: 28652058 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/23/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022] Open
Abstract
We describe the case of a 51-year-old Japanese man with an end-stage kidney disease caused by a 30-year history of type 1 diabetes mellitus. The patient had suffered repeated bilateral multiple brain infarctions within a short period of time after the initiation of a self-managed daily home hemodialysis regimen using a long-term indwelling catheter inserted into the right atrium. Despite extensive examinations, we could not find any embolic causes except for the catheter and a patent foramen ovale (PFO). The patient had experienced repeated brain infarctions under antiplatelet and anticoagulation therapies, but suffered no further brain infarctions after the removal of the catheter and the alteration of vascular access from the catheter to an arteriovenous fistula in the forearm. We speculate that the indwelling catheter-associated thrombi or air and the right-to-left shunt through the PFO may have caused the repeated paradoxical brain embolisms in this patient.
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Affiliation(s)
- Takuya Kiyohara
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Tadataka Mizoguchi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junya Kuroda
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinobu Wakisaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Aya Irie
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Chie Kitaoka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiichiro Fujisaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Udai Nakamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH. Respiratory failure in diabetic ketoacidosis. World J Diabetes 2015; 6:1009-1023. [PMID: 26240698 PMCID: PMC4515441 DOI: 10.4239/wjd.v6.i8.1009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 05/27/2015] [Indexed: 02/05/2023] Open
Abstract
Respiratory failure complicating the course of diabetic ketoacidosis (DKA) is a source of increased morbidity and mortality. Detection of respiratory failure in DKA requires focused clinical monitoring, careful interpretation of arterial blood gases, and investigation for conditions that can affect adversely the respiration. Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment. These conditions include deficits of potassium, magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema. Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system, pre-existing respiratory or neuromuscular disease and miscellaneous other conditions. Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.
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Efe SC, Poci N, Unkun T, Cap M, Acar RD, Gecmen C, Ozdemir N. Nineteen-year-old female with idiopathic thrombosis of the internal jugular vein. Perfusion 2014; 30:341-4. [PMID: 25501622 DOI: 10.1177/0267659114563780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Internal jugular vein thrombosis is a rarely seen condition which may be due to infection or neoplastic, thrombophilic, traumatic or iatrogenic causes. If the thrombosis in the jugular vein leads to pulmonary embolism, septic emboli or atrial or dural sinus thrombosis, it may be life-threatening. We report a successfully treated case of a 19-year-old female patient presenting with swelling and neck pain who was diagnosed with a stepwise approach of this rare condition.
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Affiliation(s)
- S C Efe
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - N Poci
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - T Unkun
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - M Cap
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - R D Acar
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - C Gecmen
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - N Ozdemir
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
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Donagh C, Bruzzi J, MacNeill B, DaCosta M, Berman JS, O'Regan AW. Clinical problem-solving. Looking at the whole picture. N Engl J Med 2011; 365:448-53. [PMID: 21812675 DOI: 10.1056/nejmcps1003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Carol Donagh
- Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
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Petrea RE, Koyfman F, Pikula A, Romero JR, Viereck J, Babikian VL, Kase CS, Nguyen TN. Acute stroke, catheter related venous thrombosis, and paradoxical cerebral embolism: report of two cases. J Neuroimaging 2011; 23:111-4. [PMID: 21281383 DOI: 10.1111/j.1552-6569.2010.00568.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) has been associated with cryptogenic stroke, particularly in young adults. However, the source of particles leading to cerebral embolism remains frequently unknown despite comprehensive evaluation. OBJECTIVE To report and comment on therapeutic options for 2 patients with acute ischemic strokes, PFO, and venous access related thrombosis, sources of paradoxical embolism, from Boston Medical Center stroke database. CASE DESCRIPTIONS Case 1. A 71-year-old man presented with brain magnetic resonance imaging (MRI) confirmed acute cerebellar infarction. Echocardiography showed a PFO and thrombotic material at the tip of a peripherally inserted central catheter (PICC) line in the superior vena cava (SVC) prolapsing into the right atrium (RA). Case 2. A 64-year-old woman with end-stage renal disease and PFO presented with brain MRI confirmed acute parietal lobe infarction. Three days prior to her stroke, she had thrombectomy and venoplasty of an arterio-venous (AV) dialysis graft followed by a post-thrombectomy fistulogram that showed persistent thrombotic material at the venous site. CONCLUSIONS PFO associated with large venous access site thrombosis was the most likely mechanism of stroke in both cases. Local thrombosis at sites of large venous access may be an overlooked source of paradoxical embolism in patients with PFO as well as a preventable cause of stroke in critically ill patients.
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Affiliation(s)
- Rodica Elena Petrea
- From the Department of Neurology, University of Kentucky College of Medicine, Lexington, KY 40536-0284, USA.
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Bodhey NK, Gupta AK, Sreedhar R, Manohar SRK. Retroperitoneal Hematoma: An Unusual Complication After Femoral Vein Cannulation. J Cardiothorac Vasc Anesth 2006; 20:859-61. [PMID: 17138096 DOI: 10.1053/j.jvca.2005.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Narendra K Bodhey
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, India.
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