Wide-ranging clinical spectrum of paradoxical embolism

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.

An Unusual Case of Impending Paradoxical Embolism Through a Patent Foramen Ovale in Renal Cell Carcinoma

“…A paradoxical embolism is a condition that occurs when a thrombus originating from the venous system leads to systemic embolization through an intracardiac or pulmonary shunt [ 1 ]. Based on the site of embolization, paradoxical embolism may have varied presentations, such as ischemic stroke [ 2 ], myocardial infarction, acute abdomen due to bowel ischemia, hematuria from renal infarction, or peripheral arterial occlusion. IPDE is described as the presence of thrombotic material straddling the PFO [ 3 ].…”

“…The most frequent cause of an intracardiac shunt is a patent foramen ovale (PFO). Depending on the site of the embolism, patients present with varied presentations [ 2 ]. Impending paradoxical embolism (IPDE) is described as the presence of a thrombus straddling through PFO [ 3 ].…”

New Concepts on the Pathophysiology of Acute Coronary Syndrome

“…Both atrial fibrillation (AF) and valvular heart diseases such as rheumatic valvular heart disease combined with AF can cause coronary artery embolism, and should be paid special attention to in the current era of the increasing incidence of AF. Paradoxical coronary embolism is caused by the detachment of thrombus that forms outside the coronary artery, such as deep vein thrombosis, and travel in the blood into the coronary arteries to cause ACS [ 80 ]. Last but not least, iatrogenic coronary embolism occurs during interventions in the catheterization lab or operating room, secondary to entry of surgical material, air or thrombus into the coronary arteries [ 6 ].…”