Clinical Short CommunicationParadoxical embolism through a patent foramen ovale from central venous catheter thrombosis: A potential cause of stroke
Introduction
Paradoxical embolism (PDE) is a potential condition in which an embolus arising from the venous source reaches the systemic circulation through cardiac defects and structures causing an ischemic stroke [1]. Patent foramen ovale (PFO), present in about 25% of the general population, is the most common cause of intracardiac shunting [[1], [2], [3]]. PDE occurs in the fourth-sixth decade without gender preferences [4], but it has been occasionally reported in young patients [[5], [6], [7], [8]] and infants [9], especially in the presence of thrombosis of a central venous catheter (CVC) [1,10]. Furthermore, an observational study on 144563 patients in the perioperative period after surgery showed an increased risk of stroke in the presence of a PFO [11]. Hence, PDE may become a relevant threat in consideration of the more frequent placement of CVCs in major surgery and intensive care units.
In this paper, we discuss on the diagnosis and management of PDE associated with intracardiac thrombus and PFO in a young patient carrier of a CVC.
Section snippets
Case presentation
A 39-year-old woman abruptly developed visual disturbances shortly after starting hemodialysis. She was previously well, except for a history of chronic renal failure due to bilateral ureterohydronephrosis receiving hemodialysis since the year before and a breast cancer in remission since 2014. She was on prophylactic anticoagulation with low molecular weight heparin (LMWH) (enoxaparin 100 UI/Kg) on starting dialysis. A reverse-tunnelled catheter of 15 Fr/Ch (5.0 mm) x 33 cm (PalindromeTM) had
Discussion
We reported a case of ischemic stroke during hemodialysis due to the crossing of a large CVC thrombus through a PFO, thus responsible for paradoxical embolism. We found 6 cases of PDE associated with CVC thrombosis (Table 1) [[5], [6], [7], [8], [9]], whose only one occurred during hemodialysis [8]. In our patient, we hypothesized that at the beginning of hemodialysis an increase of venous pressure in the upper vena cava could have produced a right-to-left shunt through a PFO, leading to a
Author contribution
LD, MVD and MD provided clinical care to the patient. VD drafted the first version of the manuscript, and all authors contributed to and have approved the final version of the manuscript.
Ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informant consent
Obtained.
Funding
None.
Declaration of Competing Interest
On behalf of all authors, the authors declare that there is no conflict of interest.
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