Bilateral Acute Lower Limb Ischemia Caused by Paradoxical Embolism Through a Patent Foramen Ovale Treated With the...

Paradoxical embolism (PDE) through a patent foramen ovale (PFO) is a rare cause of acute limb ischemia (ALI). When surgical thrombectomy using a Fogarty catheter is not feasible, the DISASTER technique represents a viable and effective endovascular treatment strategy.

A 51-year-old woman presented with the sudden onset of bilateral lower extremity pain and coldness. She had been receiving estrogen therapy for irregular menstruation. Angiography revealed a claw sign in the distal superficial femoral artery. She declined surgical thrombectomy due to concerns about invasiveness. Catheter-directed thrombectomy and thrombus aspiration were performed using the DISASTER (Diamond-Shaped wire Accelerate Splicing process of Thrombus used for Emergent Revascularization) technique. Ultrasound examination identified a thrombus distal to the left common femoral vein. Anticoagulation therapy with a direct oral anticoagulant (DOAC) was initiated. Comprehensive hematological testing revealed no evidence of an underlying coagulopathy. Additionally, no intracardiac thrombus or valvular vegetations were detected. Transesophageal echocardiography (TEE) identified a Grade 2 patent foramen ovale (PFO), suggesting paradoxical embolism as the likely etiology. The patient remained free of thromboembolic events postoperatively.

This report highlights the feasibility of catheter-directed thrombectomy and thrombus aspiration as an effective alternative to surgical intervention for acute limb ischemia. In cases of ALI of unknown etiology, paradoxical embolism should be suspected. Therefore, a comprehensive evaluation, including venous ultrasound and transesophageal echocardiography, is essential to identify a potential PFO or other embolic sources. Early recognition and appropriate management of paradoxical embolism may help prevent recurrent thromboembolic events and improve patient outcomes.