Clinical Short Communication
Paradoxical embolism through a patent foramen ovale from central venous catheter thrombosis: A potential cause of stroke

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Highlights

  • PDE is a potential cause of stroke in young patients with PFO.

  • PDE can occur in patients with long-term catheterization and hemodialysis.

  • Management of paradoxical embolism from central catheters is difficult.

Abstract

Paradoxical embolism refers to a potential condition in which an embolus arising from a venous source crosses into the systemic circulation through a right-to-left cardiac shunt causing an arterial embolism.

A 39-year-old woman carrier of a central venous catheter (CVC) without evident risk factors for stroke, developed an acute right homonymous hemianopia during hemodialysis. On neuroimaging, an infarct in the territory of the left posterior cerebral artery was demonstrated. Transesophageal echocardiography revealed a patent foramen ovale (PFO) and a large fluctuating thrombus in the right atrium on the tip of the CVC, thus allowing a diagnosis of ischemic stroke from paradoxical embolism. Oral anticoagulation therapy was started and the PFO was closed.

This case emphasizes the potential risk of paradoxical embolism in patients with CVCs and PFO. This condition should be prevented and identified in patients with specific risk factors, such as long-term catheterization and hemodialysis.

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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