Intraoperative identification of both a paradoxical embolism and its probable etiologic site

We report a case of upper extremity arterial ischemia in a 41-year-old man. Intraoperative transesophageal echocardiography identified a paradoxical embolization that traversed a patent foramen ovale as the probable etiology. The diagnosis of paradoxical embolism with intraoperative identification of the etiologic site of the deep venous thrombosis is a rare event. This case presents the use of transesophageal echocardiography beyond its monitoring function in helping diagnose the cause of arterial ischemia.