Vnitřní lékařství 5/2020

KAZUISTIKA Acute limb ischemia due to paradoxical embolism treated with systemic thrombolysis E48 | VNITŘNÍ LÉKAŘSTVÍ / Vnitř Lék 2020; 66(2): e48–e51 /  www.casopisvnitrnilekarstvi.cz Acute limb ischemia due to paradoxical embolism treated with systemic thrombolysis Veronika Pokorna 1 , Svetlana Bodikova 1 , Jozef Kaluzay 1 , Zuzana Liskova 2 , Olga Jurkovicova 1 1 4 th 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 pharmacomecha- nical 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. Key words: acute limb ischemia, orthopedic surgery, paradoxical embolism, patent foramen ovale, systemic thrombolysis, venous thromboembolism. Akútna končatinová ischémia v dôsledku paradoxnej embolizácie liečená systémovou trombolýzou Predstavujeme prípad pacientky s akútnou ischémiou na hornej aj dolnej končatine v dôsledku paradoxnej embolizácie. 67-ročná žena bez anamnézy venózneho tromboembolizmu utrpela v novembri 2017 dislokovanú fraktúru pately s potrebou operačného riešenia. Dva mesiace po operácii bola rehospitalizovaná pre obojstrannú embóliu do arteria pulmonalis, oklúziu ľavej arteria subclavia, ľavej arteria femoralis communis a arteria mesenterica superior. Transezofageálna echokardiografia zistila prítomnosť foramen ovale patens. Cievny chirurg neindikoval embolektómiu a intervenčný rádiológ neindikoval far- makomechanickú trombolýzu z dôvodu veľkého rozsahu oklúzie. Následne bola úspešne podaná systémová trombolýza (altepláza) s rozpustením embolov v ľavej arteria subclavia, v ľavej arteria femoralis communis a v arteria mesenterica supeior. Klíčová slova: akútna končatinová ischémia, ortopedická operácia, paradoxná embolizácia, foramen ovale patens, systémová trombolýza, venózny tromboembolizmus. Introduction Orthopedic surgery significantly increases the risk of venous thrombo‑ embolism (VTE). Major orthopedic surgery is associatedwith approximately twice the risk of VTE thanmajor general surgery (1). Timing of postoperative VTE depends on the type of surgery (2). Theminimumrecommendedphar‑ macological prophylaxis (10–14 days) is not always sufficient (3), resulting into deep vein thrombosis with/without pulmonary embolism. Significant pulmonary embolismelevates the pressure in right heart’s chambers and might cause paradoxical embolism in patients with patent foramen ovale (10–35 % of the population) (4). The emboli can affect various arteries at the same time leading e.g. to stroke, limb ischemia or visceral ischemia. There is no best recommended therapeutical approach for the treatment of multiple‑site ischemia caused by paradoxical emboli. Case description A 67-year old woman (height 163 cm, weight 85 kg, BMI 32 kg/m 2) with history of arterial hypertension, thyreopathy and hypercholes‑ terolemia, on treatment with perindopril (5 mg), amlodipin (5 mg), L‑thyroxine (50 µg) and atorvastatin (10 mg) suffered an injury of left knee with dislocated patellar fracture requiring surgery of 1 hour and KORESPONDENČNÍ ADRESA AUTORA: Veronika Pokorna, MD, PhD., MPH, vpokorna@gmail.com 4 th Department of Internal Medicine, Faculty of Medicine, Comenius University , St. Cyril and Method Hospital Antolska 11, 851 07 Bratislava, Slovak Republic Cit. zkr: Vnitř Lék 2020; 66(2): e48–e51 Článek přijat redakcí: 29. 5. 2019 Článek přijat po recenzích k publikaci: 2. 9. 2019