Clinical Case 09—Acute pulmonary embolism complicated by acute limb ischemia: a case report on the role of patent foramen ovale closure in thrombophilia

A 40-year-old obese man with hypertension and history of femoro-popliteal deep vein thrombosis (DVT), presented to the emergency department with right lower limb (RLL) ischemia associated with exertional dyspnoea for the past three weeks. Physical examination revealed a cold RLL without peripheral pulses and mild respiratory failure. Angio-CT revealed bilateral acute pulmonary embolism (APE), thrombosis of the right common iliac artery and left renal infarct (Figure 1A). Transthoracic echocardiogram revealed signs of pulmonary hypertension (PH), dilated right ventricle and a suspected patent foramen ovale (PFO) with spontaneous high volume right-to-left shunt. A diagnosis of intermediate-low risk APE with concomitant RLL acute ischemia was made. The patient underwent iliac thrombectomy, local fibrinolysis and started anticoagulation. Immunological study was positive for antiphospholipid syndrome. He recovered well and was discharged on Vitamin-K antagonists. Six months later, transoesophageal echocardiogram confirmed the PFO with persistence of right-to-left shunt with a bubble test, and recovery of the right ventricle function without signs of PH (Figure 1B). Due to the suspected paradoxical embolic event, resolution of the PH and shunt persistence, the patient underwent percutaneous PFO closure with Amplatzer PFO Occluder (25mm) [Abbott®] (Figure 1C). He has had no recurrence of thrombotic events ever since.

Concomitant arterial and venous thrombosis should prompt screening for an intracardiac shunt. Despite unclear evidence, PFO closure might reduce the risk for paradoxical embolism recurrence in a thrombophilic setting on top of oral anticoagulation.