J Thorac Cardiovasc Surg 2008;136:527-528
© 2008 The American Association for Thoracic Surgery
Life-threatening impending paradoxical embolus caught "red-handed": Successful management by multidisciplinary team approach
Cliff K. Choong, MD, MBBS, FRCS, FRACSa,b,*,
Patrick A. Calverta,
Florian Faltera,
Raj Mathurc,
Derek Appletond,
Francis C. Wellsa,
Peter M. Schofielda,
Robin Crawfordc
a Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
b Department of Surgery, University of Cambridge, Cambridge, United Kingdom
c Department of Gynaecology, The Rosie Hospital NHS Trust, Cambridge, United Kingdom
d Department of Radiology, Addenbrooke's Hospital NHS Trust, Cambridge, United Kingdom
Received for publication September 3, 2007; accepted for publication October 19, 2007.
* Address for reprints: Cliff K. Choong, MD, MBBS, FRCS, FRACS, University Lecturer, University of Cambridge, Consultant Cardiothoracic Surgeon, Papworth Hospital NHS Foundation Trust, Cambridge, CB23 8RE, United Kingdom. (Email: cliffchoong{at}hotmail.com).
Life-threatening impending paradoxical embolus is rare. We describe a case that was caught "red-handed" and successfully treated by a multidisciplinary team approach.
Clinical Summary
A 47-year-old woman presented with dyspnea and syncope. Before the presentation, she had been bed bound for 1 week after an ankle injury. During assessment, she had signs of respiratory distress but was hemodynamically stable. Blood analysis was unremarkable except for a significantly increased D-dimer. She was treated empirically with heparin for pulmonary embolism. Computed tomographic pulmonary angiography (CTPA) of the chest revealed extensive emboli in both main pulmonary arteries with filling defects in the left and right atria (Figures E1–E3). She was transferred to a tertiary cardiothoracic center. Echocardiography revealed a 9-cm–long mobile mass within the right atrium traversing through a patent foramen ovale (PFO) into the left atrium (
Figure 1, A). Whole-body computed tomography revealed an unexpected finding of a 23 x 13 x 12-cm giant uterine fibroid compressing both iliac veins with extensive thrombi in the right iliac and lower limb veins (Figures E4 and E5). There was no thrombus in the left lower limb veins. She had no history of fibroid or abdominal mass. After a multidisciplinary discussion, the patient underwent surgical embolectomy of the cardiac and pulmonary emboli with closure of the PFO. A 9 x 1.3-cm fresh embolus was removed from the PFO (Figures 1, B,
2, A and B, and E6). An inferior vena cava filter was then deployed via the left femoral vein by an interventional radiologist, followed by an ovarian-sparing hysterectomy performed by the gynecology team (Figures E7 and E8). She had a good postoperative recovery and was discharged 8 days after surgery. She has remained well for 12 months since surgery.
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Figure 1. A, Echocardiography showing a 9-cm–long mass (7 cm long in the right atrium and 2 cm long in the left atrium) traversing through a PFO. B, Nine-centimeter–long embolus removed intact.
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Figure 2. A, Paradoxical embolus traversing through a PFO. B, Paradoxical embolus traversing through a PFO.
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Discussion
The first report of paradoxical embolus was a postmortem case described by Zahn in 1881.1 He described an autopsy case that revealed thrombus in the uterine veins, multiple systemic emboli, and a branched embolus lodged in a PFO. To this day, paradoxical embolus is usually a presumptive diagnosis based on the concomitant diagnosis of venous and arterial thromboses and an abnormal connection between the venous and arterial circulations. Rarely, a dislodged thrombus will be caught "red-handed" traversing a PFO, so-called impending paradoxical embolus. In this case, it was most likely that the thrombi in the left iliac and femoral veins had dislodged and embolized to the heart and lung. CTPA has become the preferred imaging investigation in suspected pulmonary embolism.2,3 With the increasing resolution and processing speed of CTPA, we may encounter impending paradoxical embolus with increasing frequency. Because the origin of most emboli is usually femoral or iliac venous thrombi, we thought that whole-body computed tomography before surgery was useful in this case to assess for the presence of deep vein thrombosis and to search for any compressing pelvic or abdominal masses. This was performed without any significant delay to the patient's surgery. A multidisciplinary discussion in this unusual case was useful and led to the general consensus that it was important to treat both the complication and the cause in the same surgical setting by 1) removing the life-threatening impending paradoxical embolus, 2) placing an inferior vena cava filter to prevent further pulmonary embolisms,4 and 3) removing the giant fibroid to relieve the iliac venous compression and prevent development of further deep venous thrombosis. Manipulation of the pelvic veins during removal of a large uterine mass may promote embolization of any remaining thrombus; therefore, it was necessary to implant the inferior vena cava filter before the hysterectomy.4 A subsequent staged hysterectomy after the removal of the impending paradoxical embolus was discussed; however, this was considered an inferior option because it would leave the patient vulnerable to further deep venous thrombosis and pulmonary embolisms during her recovery after the cardiothoracic surgery, while awaiting the hysterectomy.
Conclusions
We have described a rare case of life-threatening impending paradoxical embolus that was successfully treated by a multidisciplinary team approach.
Figure E1
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CTPA of the chest showing multiple filling defects in the pulmonary arteries secondary to multiple pulmonary emboli.
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Figure E2
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Computed tomography showing a filling defect (arrow) caused by the presence of a soft tissue mass within the right atrium.
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Figure E3
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Computed tomography showing a filling defect (arrow) caused by the presence of a soft tissue mass within the left atrium.
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Figure E4
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Computed tomography of the abdomen showing the upper part of a giant uterine multi-fibroid (size 23 x 13 x 12 cm).
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Figure E5
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Computed tomography of the pelvis showing a giant uterine multi-fibroid (size 23 x 13 x 12 cm) compressing both iliac veins.
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Figure E6
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Some of the multiple fresh pulmonary emboli removed from bilateral pulmonary arteries. The majority of the emboli have been removed via a disposable waste suction system.
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Figure E7
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Laparotomy finding of a giant uterine multi-fibroid (size 23 x 13 x 12 cm).
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Figure E8
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Giant uterine multi-fibroid removed by an ovarian sparing hysterectomy.
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References
- Zahn FW. Med Suisse Romande 1881;1:227.
- Weiss CR, Scatarige JC, Diette GB, Haponik EF, Merriman B, Fishman EK. CT pulmonary angiography is the first-line imaging test for acute pulmonary embolism: a survey of US clinicians. Acad Radiol 2006;13:434-446.[Medline]
- Kluetz PG, White CS. Acute pulmonary embolism: imaging in the emergency department. Radiol Clin North Am 2006;44:259-271.[Medline]
- Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N Engl J Med 1998;338:409-415.[Medline]
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