The simultaneous occurrence of deep vein thrombosis and pulmonary and arterial embolization

A 45-year-old female presented with 8 hours of right lower extremity pain and dyspnea. She was tachycardic and her right lower extremity was dusky, cold, and pulseless.

Computerized tomography of the venous and arterial systems revealed massive pulmonary embolism and right lower extremity arterial and left lower extremity venous thromboses. Management included intra-arterial thrombolytics, right lower extremity arterial embolectomy, and anticoagulation. Echocardiogram revealed a patent foramen ovale (PFO) with a right-to-left shunt.

We hypothesize that our patient developed deep venous thrombosis that led to major pulmonary embolization and increased right-sided pressures. In the setting of a patent foramen ovale, a later venous embolus transversed the PFO and lodged in the femoral artery. Our case illustrates the importance of a high index of suspicion for a paradoxical embolus in patients with arterial thrombosis.