Clinical Case 04—Percutaneous patent foramen ovale closure after a thrombotic storm: a case report. (21st October 2022)

• Record Type: Journal Article
• Authors: Alexandre, André; Couto, David Sá; Luz, André; Marinho, António; Oliveira, Filomena; Silveira, João; Torres, Severo
• Is Part Of: Cardiovascular research. Volume 118(2022)Supplement 2
• Publication Date: 2022-10-21
• Subjects: Thrombotic storm -- Thrombophilia -- Hypercoagulability setting -- Patent foramen ovale -- Paradoxical embolism -- Percutaneous patent foramen ovale closure; Cardiovascular system -- Diseases -- Periodicals; Cardiovascular system -- Periodicals; 616.1
• DOI: 10.1093/cvr/cvac157.120
• Languages: English
• ISSNs: 0008-6363

Abstract

Abstract: A 38-year-old woman with a 32-week gestation was admitted in the emergency department complaining of acute lower limb pain. She had history of smoking, 1 voluntary interruption of pregnancy, 1 miscarriage at age 34, and family history of antiphospholipid syndrome (APS). At admission, bilateral acute limb ischemia and foetal death were diagnosed. CT angiography revealed acute bilateral thrombotic occlusion of the iliac arteries, left renal artery thrombosis with extension to the distal abdominal aorta, deep vein thrombosis (DVT) of the left iliac vein and distal inferior vena cava, and bilateral pulmonary embolism. The patient started on anticoagulation and underwent caesarean section and axillobifemoral bypass. Plasmapheresis and rituximab were attempted due to high clinical suspicion of catastrophic APS. Immunological and neoplastic study were repeatedly negative. The patient was ultimately discharged on vitamin K antagonist (VKA). Further investigation revealed a patent foramen ovale (PFO) with spontaneous right-to-left shunt. Given the risk of paradoxical embolism in this thrombophilic setting of unclear cause, she was referred for percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device. Post-procedure maintenance of antithrombotic therapy with VKA was decided by a multidisciplinary team. Since the event, she had no recurrence of thromboembolic events and continues under investigation in autoimmune disease outpatient clinic. Although simultaneous arterial and venous thrombosis cannot be ruled out, we suspect of left paradoxical embolism following DVT. PFO closure in this setting might be useful for reduction of paradoxical arterial embolism risk on top of systemic anticoagulation. Figure 1 Panels A and B show the presence of patent foramen ovale (PFO). Panels C and D show the final result after percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device.