Vnitr Lek 2020, 66(5):e48-e51 | DOI: 10.36290/vnl.2020.090

Acute limb ischemia due to paradoxical embolism treated with systemic thrombolysis

Veronika Pokorna1, Svetlana Bodikova1, Jozef Kaluzay1, Zuzana Liskova2, Olga Jurkovicova1
1 4th Department of Internal Medicine, Faculty of Medicine, Comenius University in Bratislava and University Hospital Bratislava, St. Cyril and Method Hospital, Slovak republic
2 Rádiológia, s. r. o., University Hospital Bratislava, St. Cyril and Method Hospital, Slovak Republic

We present a case report of a patient with acute upper and lower limb ischemia due to paradoxical embolism. A 67-year old woman without history of venous thromboembolism suffered dislocated patellar fracture requiring surgery in November 2017. Two months after surgery she presented to the emergency room with bilateral pulmonary embolism, occlusion of the left subclavian artery, left common femoral artery and superior mesenteric artery. Transesophageal echocardiography detected patent foramen ovale. Vascular surgeon decided against embolectomy, interventional radiologist against pharmacomechanical thrombolysis due to the extent of the occlusions. Systemic thrombolysis (alteplase) was administered successfully with resolution of the emboli in the left subclavian artery, left common femoral artery and superior mesenteric artery.

Keywords: Key words: acute limb ischemia, orthopedic surgery, paradoxical embolism, patent foramen ovale, systemic thrombolysis, venous thromboembolism.

Published: August 1, 2020  Show citation

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Pokorna V, Bodikova S, Kaluzay J, Liskova Z, Jurkovicova O. Acute limb ischemia due to paradoxical embolism treated with systemic thrombolysis. Vnitr Lek. 2020;66(5):e48-51. doi: 10.36290/vnl.2020.090.
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    References

    1. White RH, Romano PS, Zhou H, et al. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158: 1525-1531. Go to original source... Go to PubMed...
    2. Kearon C. Natural history of venous thromboembolism. Circulation 2003; 107: (23 Suppl 1): 122-130. Go to original source... Go to PubMed...
    3. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‑Based Clinical Practice Guidelines. Chest 2012; 141: (2 Suppl): e419S-e496S. Go to original source...
    4. Fisher DC, Fisher EA, Budd JH, et al. The incidence of patent foramen ovale in 1,000 consecutive patients. A contrast transesophageal echocardiography study. Chest 1995; 107: 1504-1509. Go to original source... Go to PubMed...
    5. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3033-3069, 3069a-3069k.
    6. Douketis JD, Eikelboom JW, Quinlan DJ, et al. Short‑duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta‑analysis of prospective studies investigating symptomatic outcomes. Arch Intern Med 2002; 162: 1465-1471. Go to original source... Go to PubMed...
    7. Comp PC, Spiro TE, Friedman RJ, et al. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. J Bone Joint Surg Am 2001; 83: 336-345. Go to original source... Go to PubMed...
    8. Konstantinides S, Geibel A, Kasper W, et al. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998; 97: 1946-1951. Go to original source... Go to PubMed...
    9. AbuRahma AF, Downham L. The role of paradoxical arterial emboli of the extremities. Am J Surg 1996; 172: 214-217. Go to original source... Go to PubMed...
    10. Acosta S, Bjorck M. Acute thrombo‑embolic occlusion of the superior mesenteric artery: a prospective study in a well defined population. Eur J Vasc Endovasc Surg 2003; 26: 179-183. Go to original source... Go to PubMed...
    11. Pirkl M, Myjavec A, Danek T, et al. A case of pulmonary thromboembolism with synchronous and metachronous paradoxical embolism through the patent foramen ovale. Cor et Vasa 2012; 54: E314-E322. Go to original source...
    12. Fan Z, Roedersheimer R, Lohr J. Systemic thrombolysis using tissue plasminogen activator for a patient with paradoxic embolism: a case report. Vasc Endovascular Surg 2007; 41: 136-139. Go to original source... Go to PubMed...
    13. Agarwal SK, Binbrek AS, Thompson JA, et al. Massive pulmonary embolism and acute limb ischaemia in a patient of hereditary spherocytosis and patent foramen ovale. Heart Lung Circ 2010; 19: 742-744. Go to original source... Go to PubMed...
    14. Ruiz‑Bailen M, Ramos‑Cuadra JA, Machado‑Casas J, et al. Successful administration of alteplase in a venous thromboembolism crossing through a patent foramen ovale. Interact Cardiovasc Thorac Surg 2009; 9: 712-713. Go to original source... Go to PubMed...
    15. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018; 39: 763-816. Go to original source... Go to PubMed...
    16. Murthy V, Murray D, Hebballi S, et al. Outcome of liver transplantation in patients with hereditary bleeding disorders: a single centre UK experience. Haemophilia 2016; 22: e139-e144. Go to original source... Go to PubMed...
    17. Khakhar AK, Chan NG, Allan DS, et al. Catastrophic microangiopathy induced by high‑titre factor VIII inhibitors after liver transplantation for haemophilia A with cirrhosis. Haemophilia 2005; 11: 623-628. Go to original source... Go to PubMed...
    18. Srivastava A, Brewer AK, Mauser‑Bunschoten EP, et al. Guidelines for the management of hemophilia. Haemophilia 2013; 19: e1-e47. Go to original source... Go to PubMed...
    19. Merlen C, Zourikian N, Bonnefoy A, et al. Effect of ABO blood group on haemostatic parameters in severe haemophilia A patients performing acute moderate‑intensity exercise. Blood Coagul Fibrinolysis 2018; 29: 626-635. Go to original source... Go to PubMed...
    20. Shapiro AD, Korth‑Bradley J, Poon MC. Use of pharmacokinetics in the coagulation factor treatment of patients with haemophilia. Haemophilia 2005; 11: 571-582. Go to original source... Go to PubMed...
    21. Björkman S, Folkesson A, Berntorp E. In vivo recovery of factor VIII and factor IX: intra- and interindividual variance in a clinical setting. Haemophilia 2007; 13: 2-8. Go to original source... Go to PubMed...
    22. Hazendonka HCAM, van Moorta I, Mathô RAA, et al. Setting the stage for individualized therapy in hemophilia: What role can pharmacokinetics play? Blood Rev 2018; 32: 265-271. Go to original source... Go to PubMed...
    23. Togashi J, Akamatsu N, Tanaka T, et al. Living donor liver transplantation for hemophilia with special reference to the management of perioperative clotting factor replacement. Liver Transplant 2016; 22: 366-370. Go to original source... Go to PubMed...
    24. Ragni MV, Devera ME, Roland ME, et al. Liver transplant outcomes in HIV+ haemophilic men. Haemophilia 2013; 19: 134-140. Go to original source... Go to PubMed...
    25. Yokoyama S, Bartlett A, Dar FS, et al. Outcome of liver transplantation for haemophilia. HPB (Oxford) 2011; 13: 40-45. Go to original source... Go to PubMed...
    26. Goldmann G, Zeitler H, Marquardt N, et al. Long‑term outcome of liver transplantation in HCV/HIV coinfected haemophilia patients. A single centre study of 10 patients. Hamostaseologie 2015; 35: 175-180. Go to original source... Go to PubMed...
    27. Park YK, Kim HC, Kim BW, et al. Auxiliary partial orthotopic liver transplantation as a treatment for hemophilia a: a case report. Transplant Proc 2015; 47: 161-164. Go to original source... Go to PubMed...
    28. Charvát J, Vychodil P, Adamec M, et al. Vyléčení těžké formy hemofilie A transplantací jater - kazuistika. Trombóza a hemostáza. Hradec Králové: HK Credit 2007, 114 s.
    29. Zieve L. Jaundice, hyperlipidemia, and hemolyticanemia: here to for eunrecognized syndrome associated with fatty liver and cirrhosis. Ann Intern Med 1958; 48; 471. Go to original source... Go to PubMed...
    30. Deleuran T, et al. Cirrhosis and mortality risk of biopsy‑verified alcoholic pure steatosis and steatohepatitis: a nationwide registry‑based study. Aliment Pharmacol Ther 2012; 35; 1336-1342. Go to original source... Go to PubMed...
    31. Lacnetr C et al: Histological parametres and alcohol abstinence determine long‑term prognosis in patiens with alcoholic liver disease. J Hepatol 2017; 66; 610-618. Go to original source... Go to PubMed...
    32. Kennedy OJ, et al. Systematic review with meta‑analysis: coffee consumption and risk of cirrhosis. Aliment Pharmacol Ther 2016; 43; 562-574. Go to original source... Go to PubMed...
    33. Sherlock S. Nutritional disease. In: Diseases of the Liver and Biliary System. Illionis USA, Charles C Thomas Publisher 1954, 276-304.
    34. Menghini G. One‑second needle biopsy of the liver. Gastroenterology 1958; 35; 190. Go to original source...
    35. Amstrong MJ, et al. Extrahepatic complication of nonalcoholic fatty liver disease. Hepatology 2014; 59; 1174-1197. Go to original source... Go to PubMed...
    36. Sandahl TD, Jepsen P, Thomsen KL, et al. Incidence and mortality of alcoholic hepatitis in Denmark 1999-2008: a nationwide population based cohort study. J Hepatol 2011; 54: 760-764. Go to original source... Go to PubMed...
    37. Michelena J, Altamirano J, Abraldes JG, et al. Systemic inflammatory response and serum lipopolysaccharide levels predict multiple organ failure and death in alcoholic hepatitis. Hepatology 2015; 62: 762-772. Go to original source... Go to PubMed...
    38. Maddrey WC, Boitnott JK, Bedine MS, et al. Corticosteroid therapy of alcoholic hepatitis. Gastroenterology 1978; 75: 193-199. Go to original source...
    39. Moreau R, Jalan R, Gines P, et al. Acute‑on‑chronic liver failure is a distinct syndrome that develops in patiens with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426-1437. Go to original source... Go to PubMed...
    40. Kribben A, Gerken G, Haag S, et al. Effects of fractionated plasma separation and adsorption on survival in patients with acute‑on‑chronic liver failure. Gastroenterology 2012; 142; 782-789. Go to original source... Go to PubMed...
    41. Kjaergard LL, Liu J, Nielsen B, et al. Artificial and bioartificial support systems for acute and acute‑on‑chronic liver failure: a systematic review. JAMA 2003; 289: 217-222. Go to original source... Go to PubMed...
    42. Arroyo V, Moreau R, Kamath PS, et al. Acute‑on‑chronic liver failure in cirrhosis. Nat Rev Dis Primers 2016; 2: 41-160. Go to original source... Go to PubMed...
    43. Heemann U, Treichel U, Loock J et al. Albumin dialysis in cirrhosis with super imposed acute liver injury: a prospective, controlled study. Hepatology 2002; 36; 949-958. Go to original source... Go to PubMed...
    44. Bañares R, Nevens F, Larsen FS, et al. Extracorporal albumin dialysis with the molecular adsorbent recirculating system in acute‑on‑chronic liver failure: the RELIEF trial. Hepatology 2013; 57: 1153-1162. Go to original source... Go to PubMed...
    45. Finkenstedt A, Nachbaur K, Zoller H, et al. Acute‑on‑chronic liver failure: excedent outcomes after liver transplantation but high mortality on the wait list. Liver Transpl 2013; 19: 879-886. Go to original source... Go to PubMed...
    46. Adam R, McMaster P, O'Grady, et al. Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry. LiverTranspl 2003; 9: 1231-1243. Go to original source... Go to PubMed...
    47. Friedman SL. Liver fibrosis - from bench to bedside. J Hepatol 2003; 38: (Suppl. 1); 38-53. Go to original source... Go to PubMed...
    48. Aiglová K. Noninvasive alteratives of liver biopsy. In Takahashi H (ed.) Liverbiopsy. Rijeka: Intech open Access 2016; 297-304.
    49. Jalan J, Olson JC, et al. Acute‑on‑chronic liver failure. J Hepatol 2012; 57; 1336-1348. Go to original source... Go to PubMed...
    50. Trunečka P. Transplantace jater. In: Hůlek P, Urbánek P et al (eds.): Hepatologie 3. vydání. Praha: Grada Publishing 2018, 625-647.
    51. Aiglová K. Jaterní fibróza a její diagnostika. Postgrad med 2012; 3; 297-304.
    52. Burra P, Senzolo M, Adam R, et al. Liver transplantation for alcoholic liver disease in Europe: a study from the ELTR (European Liver Transplant Registry). Am J Transplant 2010; 10: 138-148. Go to original source... Go to PubMed...
    53. Addolorato G, Bataller R, Burra P, et al. Liver transplantation for alcoholic liver disease. Transplantation 2016; 100: 981-987. Go to original source... Go to PubMed...
    54. MacSween RN, Burt AD. Histologic spectrum of alcoholic liver disease. Semin Liver Dis 1986; 6: 221-232. Go to original source... Go to PubMed...

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