Diagnosis and treatment of paradoxical embolus

Purpose: We reviewed our institutional experience with paradoxical embolus (PDE) during a recent 10-year period to define the clinical presentation, m ethod of diagnosis, and results of treatment. Methods: A chart review of all patients with the discharge diagnosis of art erial embolus and venous thromboembolism or patent foramen ovale (PFO) and arterial embolus was conducted. Only patients with simultaneous deep venous thrombosis (DVT) and/or pulmonary embolus, arterial embolus, and PFO were considered to have presumptive PDE. Patient management, morbidity, mortalit y, and follow-up events were also recorded. Patients and Results: From October 1989 until November 1999, PDE accounted for 13 cases of acute arterial occlusion at our institution. There were sev en men and six women (mean age, 57 +/- 11 years). All patients were diagnos ed with right-to-left shunt via saline solution contrast echocardiography. Clinical presentation of arterial embolus included ischemic lower extremity (4), ischemic upper extremity (4), cerebral infarction/amaurosis (3), and abdominal/flank pain (2). Five patients also presented with concomitant res piratory distress. Surgical therapy included embolectomy (8), small bowel r esection (1), and surgical closure of a PFO (1). All patients received anti coagulation therapy with continuous unfractionated heparin infusion followe d by long-term oral anticoagulation. Five inferior vena caval filters were placed. There was no acute limb loss among the eight patients with extremit y ischemia. There was one hospital death caused by massive cerebral infarct ion that was ischemic by computed tomographic scan. Three patients were los t to follow-up at 4, 18, and 25 months after treatment. Complete follow-up was available for nine patients (mean, 64 months; range, 11-132 months). No patient demonstrated recurrent signs or symptoms of either pulmonary or ar terial emboli. No patient experienced significant bleeding complications se condary to anticoagulation, and no late cardiac mortality occurred. Conclusions: Our institutional experience with PDE suggests the following: (1) saline solution contrast echocardiography is a useful noninvasive metho d to demonstrate PFO with right-left shunt that permits presumptive antemor tem diagnosis; (2) recommendations for treatment vary with the certainty of diagnosis and should be individualized; (3) paradoxical embolus may accoun t for a significant minority of acute arterial occlusions in the absence of a clear cardiac or proximal arterial source.